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Table of Contents
LETTER TO THE EDITOR
Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 191-193

Management of right-sided polyorchidism with torsion: A case report with literature review


Department of Urology, Showa University School of Medicine, Tokyo, Japan

Date of Submission26-Dec-2018
Date of Decision20-Feb-2019
Date of Acceptance11-Mar-2019
Date of Web Publication29-Jul-2019

Correspondence Address:
Sat Prasad Nepal
Department of Urology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo 142-8555
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_149_18

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  Abstract 


Polyorchidism is a rare congenital condition associated with various anomalies; triorchidism is the most common form of this condition. A 21-year-old patient visited our hospital with pain in the right testis. He was diagnosed with right-sided polyorchidism with torsion and underwent manual detorsion followed by orchidopexy. We preserved the extra testis but did not perform histology, as radiological examination revealed no malignant features.

Keywords: Polyorchidism, supernumerary testis, ultrasonography


How to cite this article:
Nepal SP, Nakasato T, Naoe M, Shimoyama H, Ogawa Y, Fuji K, Maeda Y, Morita J, Oshinomi K, Matsui Y, Unoki T, Hiramatsu A. Management of right-sided polyorchidism with torsion: A case report with literature review. Urol Sci 2019;30:191-3

How to cite this URL:
Nepal SP, Nakasato T, Naoe M, Shimoyama H, Ogawa Y, Fuji K, Maeda Y, Morita J, Oshinomi K, Matsui Y, Unoki T, Hiramatsu A. Management of right-sided polyorchidism with torsion: A case report with literature review. Urol Sci [serial online] 2019 [cited 2019 Oct 13];30:191-3. Available from: http://www.e-urol-sci.com/text.asp?2019/30/4/191/263647




  Introduction Top


Polyorchidism is a rare congenital anomaly of the genital tract, and for which, no >200 cases have been reported in the literature. It is defined by the presence of >2 testes, and supernumerary testes mainly occur on the left side.[1],[2] Patients with polyorchidism may present with a painless mass in the scrotum, inguinal mass, undescended testis, or an accessory testis with torsion.[3] Ultrasonography (USG) is used for diagnosis and magnetic resonance imaging (MRI) to confirm the USG findings.[1],[4],[5],[6] On surgical exploration, the current literature recommends the histological examination in complicated cases.[2]


  Case Report Top


A 21-year-old male visited our hospital with pain in the right testis. He had no significant past medical or surgical history, including a history of genital trauma or lower urinary tract symptoms. On examination, his right testicle was higher than the left, immovable, and had a mass in the inferior portion; the patient had been aware of the mass for a long time [Figure 1]. We suspected testicular torsion and performed USG. The right testis, which measured 2.0 cm × 2.1 cm × 2.0 cm in size and 4.37 cc in volume, contained an additional, smaller mass with similar echogenicity, measuring 1.2 cm × 1.4 cm × 1.3 cm in size and 1.14 cc in volume. However, the vas deferens and epididymis could not be identified. The left testis measured 2.0 cm × 4.3 cm × 1.97 cm in size and 8.81 cc in volume. Blood flow to the right testes was reduced. MRI also revealed the presence of two right testes [Figure 2]. His semen analysis was normal (3.3 ml volume, 121 million sperm per ml, and 40% motility). Manual detorsion of the right testicle was performed and gave him relief from his pain.
Figure 1: Ultrasonography indicated the presence of two right testes

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Figure 2: Coronal magnetic resonance image confirmed the small right testis located inferior to the large right testis

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In surgery, the large testis was found to be cranially located, measuring 2.5 cm; the small testis measured 1 cm [Figure 3]. Both testes had separate epididymis with a common vas deferens. The smaller testis had its own blood supply, but the artery and vein could not be distinguished. The appendix testis could not be identified.
Figure 3: Discovered two right testes. (A) Large right testis. (B) Small right testis. 1: blood vessels in the small right testis, 2: the epididymis of the large right testis, 3: the epididymis of the small right testis, 4: the vas deferens of both testes

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The epididymis of the large right testis was connected to the epididymis of the small right testis, both of which were joined to a single vas deferens. The tunica albuginea of both testes was fixed into the scrotum to prevent torsion. Left testis was also fixed. Follow-up USG showed no abnormalities in the right testes.


  Discussion Top


Triorchidism (three testes) is the most common form of polyorchidism, a rare anomaly of the testis. Supernumerary testes are located in the scrotal (66%), inguinal (23%), or abdominal (9%) region, and only 30% are found on the right side.[2] The median age at presentation is 17 years.[2] There is a 6.4% chance of malignancy associated with polyorchidism, with cryptorchidism (i.e., undescended testis) being one of the risk factors.[2]

In most cases, polyorchidism is discovered by accident. Common presentations associated with supernumerary testis are testicular maldescent (22%–40%), hernia (24%–30%), painless scrotal or inguinal swelling (16%), torsion (15%), hydrocele (9%), pain (7%), malignancy (6%), and varicocele (1.4%).[2],[5],[7],[8]

Various classifications of polyorchidism are found in the literature.[1],[2],[3],[5] Our patient had Type A2 polyorchidism according to the Bergholz classification, which is based on the anatomy and reproductive potential of the supernumerary testis [Table 1].[2]
Table 1: The Bergholz classification of polyorchidism

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The diagnosis of polyorchidism is made by USG.[1] The supernumerary testis has similar echogenicity and vascular flow to those of the normal testis.[1] MRI is used to support or confirm USG findings.[1],[4],[5],[6] MRI shows an intermediate signal on T1-weighted images and high signal intensity on T2.[1]

Urologists must decide either to remove or preserve a supernumerary testis. Infertility associated with this condition prompts preservation.[6] On the other hand, polyorchidism is associated with an increased risk of malignancy and torsion, and thus, removal of the supernumerary testis may be recommended.[2] In the literature, management strategies for polyorchidism are based on the associated symptoms, location, and drainage of the supernumerary testis.[2]

Our management of Bergholz Type A2 triorchidism with testicular torsion depended on the ischemic state of the testes, suspicion of malignancy based on radiological findings, scrotal location of the testis, and drainage by vas deferens, irrespective of the age.

We decided to preserve the supernumerary testis because of its attachment to the vas deferens implying reproductive potential. We did not perform histology as no malignant features were observed radiologically. Annual follow-up is planned for this patient.


  Conclusion Top


Right-sided supernumerary testis is rare. We used USG to diagnose polyorchidism and decided to preserve the supernumerary testis without histological examination, as the testes were drained by a common vas deferens and radiological findings revealed no malignant features.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Artul S, Habib G. Polyorchidism: Two case reports and a review of the literature. J Med Case Rep 2014;8:464.  Back to cited text no. 1
    
2.
Bergholz R, Wenke K. Polyorchidism: A meta-analysis. J Urol 2009;182:2422-7.  Back to cited text no. 2
    
3.
Haddock G, Burns HJ. Polyorchidism. Postgrad Med J 1987;63:703-5.  Back to cited text no. 3
    
4.
Duymuş M, Menzilcioǧlu MS, Çetinçakmak M, Avcu S. A rare case of polyorchidism: Four testes. Pol J Radiol 2016;81:39-41.  Back to cited text no. 4
    
5.
Kumar B, Sharma C, Sinha DD. Supernumerary testis: A case report and review of literature. J Pediatr Surg 2008;43:E9-10.  Back to cited text no. 5
    
6.
Bhogal RH, Palit A, Prasad KK. Conservative management of polyorchidism in a young man: A case report and review of literature. Pediatr Surg Int 2007;23:689-91.  Back to cited text no. 6
    
7.
Yeniyol CO, Nergiz N, Tuna A. Abdominal polyorchidism: A case report and review of the literature. Int Urol Nephrol 2004;36:407-8.  Back to cited text no. 7
    
8.
Studniarek M, Skrobisz-Balandowska K, Modzelewska E. Scrotal imaging. J Ultrason 2015;15:245-58.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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