Discontinued Splenogonadal Fusion and Bilateral Empty Scrotum in an 18-Month-Old Boy

The continuous type of splenogonadal fusion: A rare case report and literature review

INTRODUCTION

We report a rare case of the continuous type of splenogonadal fusion (SGF) in a young adolescent with preserved testis.

CASE PRESENTATION

A 19-year-old male patient with a history of left inguinal hernia repair 10 years ago presented with a palpable mass on the left side. Computed tomography revealed a 58x37mm mass with a tissue density of 47HU, demonstrating vigorous enhancement following contrast administration and displaying well-defined margins with the left testicle. It was noted to be growing vertically in the left inguinal canal and to be continuous with the lower pole of the native spleen. The patient underwent laparoscopic surgery to remove the splenic tail in the abdomen and to separate the scrotal spleen from the left testicle through the left inguinal tract. The histopathological examination confirmed the presence of splenic tissue.

DISCUSSION

SGF is often diagnosed incidentally during exploration or surgery for scrotal swelling or mass, cryptorchidism, or inguinal hernia in young patients. It is important to be aware of this condition to avoid unnecessary radical orchiectomy.

CONCLUSION

Diagnosing the SGF preoperatively can be challenging. However, a combination of imaging modalities and negative tests for alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and beta-human chorionic gonadotropin (b-HCG) can aid in making an initial diagnosis. The use of laparoscopic surgery can further improve the diagnostic process, allowing clinicians to accurately diagnose SGF and make well-informed treatment decisions.

Splenogonadal fusion- a great clinical masquerader: a case report and review of literature

Background

Splenogonadal fusion (SGF) is a rare developmental choristoma in which ectopic splenic tissue is aberrantly attached to the gonads, mostly in the scrotum. It is a great clinical masquerader, and accurate preoperative diagnosis is often difficult due to the rarity of this entity. Many patients tend to undergo unnecessary surgical explorations and also orchiectomy. Accordingly, this article aims to review the latest literature regarding SGF and a description of the radiological features of this rare entity. Multiple systematic methods were used to find the latest publications on splenogonadal fusion by searching the Scopus, PubMed, and Google Scholar databases online since 2013. The latest comprehensive review of this rare entity was of 61 cases by Malik et al. in 2013. We reviewed all the cases of SGF reported in the literature in the last 10 years between 2013 and 2022 with an emphasis on diverse clinical presentations and radiologic findings. Along with this, a surgical and pathological proved case of SGF will be presented with emphasis on imaging findings. Splenogondal fusion is an uncommon differential diagnosis in patients with scrotal swelling. The current literature review showed the discontinuous type (63%) of SGF to be more common than the continuous (37%) type in contradiction to the previous literature review. Orchiectomy was done in 36% of cases as compared to 24% as described in the latest review by Malik et al.

Conclusions

Knowledge of this entity along with familiarization with its imaging features among radiologists is essential for surgical prognostication and avoiding unnecessary orchiectomy. We suggest that the addition of colour Doppler and elastography to routine grey-scale ultrasound can increase diagnostic confidence. Subsequent cross-sectional imaging with magnetic resonance imaging (MRI) helps categorize the subtype and pre-operative planning.

A case of splenogonadal fusion in the left testis

Splenic tissue outside the normal anatomical site can be collectively referred to as ectopic spleen. Clinically, the commonest causes of ectopic spleen include accessory spleen, splenic tissue implantation, and splenogonadal fusion (SGF). Accessory spleen is mostly caused by congenital dysplasia, is mostly located near the spleen, and may be supplied by the splenic artery. Splenic implantation is mostly caused by autologous spleen tissue transplantation caused by trauma or surgery. SGF is the abnormal fusion of the spleen with the gonad or with the mesonephric derivatives. As a rare developmental malformation, it is difficult to make a correct diagnosis preoperatively, and easily misdiagnosed as a testicular tumor cause lifelong harm to patients. An 18-year-old male student who developed left testicular pain without obvious cause that radiated to the perineum 4 months prior to presentation. He was diagnosed with cryptorchidism 12 years ago and underwent orchiopexy without intraoperative frozen section examination. An ultrasound was performed, identifying hypoechoic nodules in the left testis, suggestive of seminoma. During surgery, the testicular tumor revealed a dark red tissue and the diagnosis of a pathological ectopic splenic tissue was made. Because the clinical manifestations of SGF are not specific, misdiagnosis and unnecessary orchiectomy may occur. If a complete preoperative examination which includes biopsy or intraoperative frozen section is performed, unnecessary orchiectomy can be effectively avoided and bilateral fertility can be preserved.

Seminoma arising in splenogonadal fusion: a case report and literature review

BACKGROUND

Splenogonadal fusion (SGF) is a rare congenital malformation in which the spleen is abnormally connected to the gonads or to the mesonephric derivatives. There is no obvious causality between SGF and testicular neoplasm. However, cryptorchidism, which is a well-known risk factor of testicular germ cell tumors, are the most frequent malformations associated with SGF. To our knowledge, there are only four reported cases of SGF associated with testicular neoplasm so far. Herein, we reported a patient of this condition, and briefly reviewed the related literature.

CASE PRESENTATION

A 48-year-old man was diagnosed with bilateral cryptorchidism 30 years prior, and only underwent a right orchiopexy for the left testicle could not be explored during the operation. At that time, doctors failed to realize the possibility of SGF due to the lack of sufficient knowledge of this condition. This time, the patient was treated for a left abdomen mass that was diagnosed as stage III metastatic seminoma. Then, a right orchiectomy, robot-assisted laparoscopic left retroperitoneal tumor resection, and left retroperitoneal lymph node dissection was performed after four cycles of BEP (bleomycin + etoposide + cisplatin) systemic chemotherapy in our center. The final diagnosis of SGF was made by postoperative pathology. The patient was re-examined in our center at 3 months and 6 months after the operation, and no obvious abnormalities were found.

CONCLUSIONS

Surgeons should always bear in mind the possibility of association between bilateral cryptorchidism and splenogonadal fusion to avoid malignant transformation caused by delayed treatment.

Splenogonadal fusion: a case report and review of the literature

Background

Splenogondal fusion (SGF) is a rare congenital anomaly characterized by abnormal association between the splenic tissue and the gonads or mesonephric remnants. SGF that requires separate two-stage laparoscopic staged Fowler-Stephen orchiopexy on both the left and right sides is extremely rare. SGF could be misdiagnosed as testicular malignancy and leads to unnecessary orchiectomy.

Case presentation

This is a case of an 8-month old male infant presented with bilateral cryptorchidism, B-mode ultrasound visualized the left and right testes in the lower abdominal cavity and the upper margin of the left testicle as a hypoechoic mass extending to the spleen, indicating an undescended right testis and possible SGF on the left side. Single-site laparoscopic examination confirmed the diagnosis of SGF on the left side and an undescended right testis. As both testes were high and the right spermatic vessel was poorly developed and short, a routine single stage orchiopexy would be difficult and risky, therefore, separate two-stage laparoscopic staged Fowler-Stephen orchiopexies for both sides were implemented. Stage 1 of the staged Fowler-Stephen orchiopexy for the right side was performed first without treating the left side, Stage 2 for the right side, separation of the left testis from the spleen as well as Stage 1 for the left side were performed 7 months later, and Stage 2 for the left side was performed 7 months after that. Follow-up ultrasound 1 year after the surgery revealed no obvious abnormalities in the shapes of the testes or their blood supply. This treatment strategy prevented unnecessary orchiectomy.

Conclusions

We reported a rare case of SGF that needed separate two-stage laparoscopic staged Fowler-Stephen orchiopexies for both sides, and a review of the recent literature. SGF is a rare congenital anomaly often diagnosed incidentally during exploration/surgery for scrotal swelling/mass, cryptorchidism or inguinal hernia in young patients. Surgeons, especially pediatric surgeons should be aware of this rare condition to avoid unnecessary, life-altering radical orchiectomy. When routine single stage orchiopexy is not feasible or risky for either side, separate two-stage laparoscopic staged Fowler-Stephen orchiopexies could be performed on both the left and right sides to avoid unnecessary orchiectomy.

[A CASE OF SPLENOGONADAL FUSION PRESENTING NON-PALPABLE TESTIS AND PROXIMAL HYPOSPADIAS]

A 9-month-old boy, having a history of cardiac surgery in neonatal period, was referred to our department for evaluation of genital anomalies. The antenatal course was uneventful, except for unknown gender. His family history was unremarkable. He was delivered at full term, and his birth weight was 3,510 g. Physical examination revealed proximal hypospadias and a non-palpable testis on the left side. Chromosome studies showed a normal male karyotype with positive SRY. At the age of 14 months, he underwent hypospadias repair. Three months later, left testicular exploration was performed along with orchidopexy of an ascending testis on the contralateral side. As nothing was found through an inguinal incision on the left side, laparoscopy was indicated. Laparoscopic observation revealed a small dark reddish mass cranially connected to the left hypoplastic testis that was located high in the left iliac fossa. The epididymis and vas deference looked abnormal, and detachment to the testis was apparent. Testicular vessels were undifferentiated from the mass. Therefore, the left testis was excised with the mass. Histopathological examination confirmed the testis and spleen tissue, and the diagnosis of splenogonadal fusion was made postoperatively.