Embryological basis of polyorchidism including classification, reproductive potential, and risk of malignancy: A review

Polyorchidism, a congenital malformation characterized by supernumerary testes (SNTs), is usually revealed incidentally during ultrasound or open scrotal surgery. In the approximately 200 cases so far published in the literature, the left side is affected more often than the right. Despite the rarity of this anomaly, a surgeon must have basic knowledge of its embryological basis and classifications to implement proper treatment and avoid overlooking it, since the consequences could harm the patient. This review summarizes previous classifications. It can be assumed that determining the risk of malignancy, and the level of reproductive potential based on location, vascularization, ductus deferens drainage, and environmental factors (e.g., temperature) affecting the SNTs, indicates the best approach to management. Therefore, we have created a new classification based on previous ones, addressing the aforementioned issues, which will guide the clinician to select the most appropriate treatment.

Inguinal Polyorchidism Found Incidentally During Orchiopexy in 9-Year-Old Male: A Case Report and Review of Orchiopexy of Nonscrotal Supernumerary Testes

Polyorchidism, the presence of more than two testes, usually presents as a painless scrotal mass or is diagnosed incidentally during the management of another condition.1 It is a rare congenital abnormality with approximately 200 reported cases in the literature. Most cases are found on the left side within the scrotum. We report a case of right-sided polyorchidism in a 9-year-old patient found incidentally during inguinal orchiopexy. As there is debate on the management of polyorchidism, a careful approach is required as the surgeon must decide between either scrotal fixation or the removal of the supernumerary testis. This case report will discuss the anatomical and clinical considerations when making this decision.

Polyorchidism: An Up-to-Date Systematic Review

Polyorchidism is a rare male urogenital tract anomaly characterized by at least one supernumerary testis in the scrotum or ectopically. According to data based on our systematic review, 76% of the supernumerary testes (SNTs) were located in the scrotum, and 24% were extra-scrotal (p < 0.001). Among testes located outside the scrotum, 87% were found in the inguinal canal and 13% in the abdominal cavity. In 80% of cases, the diagnosis of SNT was made based on imaging tests, and the remaining 20% of cases were detected incidentally during surgery. The imaging tests performed (US or MRI) resulted in a significantly higher rate of patients who qualified for observation vs. surgical treatment (45% vs. 35%, p < 0.001). The most common conditions associated with SNT were ipsilateral inguinal hernia (15% of cases) and cryptorchidism (15% of cases). Surgery (orchidopexy/orchidectomy) was performed on 54% of patients with SNT, and the decision to observe the SNT was made in a total of 46% of patients (p = 0.001). The therapeutic approach depends on the location of the SNT and the presence of factors that raise suspicion of neoplastic proliferation.

Pentaorchidism diagnosed on ultrasound examination: A case report and literature review

Polyorchidism is a congenital malformation of the urogenital system that is usually found incidentally in adolescent age groups. Ultrasound and MRI are effective non-invasive diagnostic modalities which can differentiate this condition from other intrascrotal pathologies. Ultrasonography is mostly used in initial steps of diagnostic approach; however, MRI is considered as a modality to confirm diagnosis and evaluate possible malignancy. We report an extremely rare case of pentaorchidism (five testicles), presented with a left hemiscrotum mass. Diagnosis was made based on physical examination, laboratory analysis (testicular germ cell tumour markers and semen analysis) and imaging. Finally, close surveillance with ultrasound and physical examination was recommended for follow-up of this uncomplicated patient.

A case of triorchidism

We present the case of an adolescent male who presented with a painless left scrotal lump. Investigations revealed a diagnosis of a supernumerary testicle or polyorchidism. In this case report we discuss the imaging findings of polyorchidism on different modalities. We examine how imaging can be used to diagnose and classify this condition. We also discuss the associated complications and the role of imaging in surveillance and management of this rare disorder.

[PUBERTAL TESTICULAR TORSION OF POLYORCHIDISM DIAGNOSED IN INFANCY: A CASE REPORT]

Left polyorchidism was found in a 2-month-old boy with a left scrotal mass. As he was asymptomatic and all testes were in the scrotum, he was conservatively followed up. At 17 years of age, he presented with left acute scrotum due to testicular torsion of the left supernumerary testis. Counterclockwise 720-degree rotation of the left supernumerary testis was noted during emergency surgery, and orchidopexy of the 3 testes (2 left testes and 1 right testis) was performed. Biopsy of the left supernumerary testis demonstrated spermatogenesis and no malignancy. One and a half years after surgery, all testes were viable without atrophy.Polyorchidism is a rare condition and there is no consensus on the management of asymptomatic cases detected early in life. The position of the supernumerary testis (intrascrotal or extrascrotal) is important when deciding the management strategy because of the risk of malignancy. If conservative management is selected initially, elective surgery, such as prophylactic orchiectomy or orchidopexy, may be needed because of the risk of malignancy and torsion.

POLYORCHIDISM DISCOVERED AS AN INCIDENTAL FINDING IN 16 YEARS BOY DURING LEFT INGUINAL HERNIOTOMY

A 16 years old boy presented with three months history of left inguinal hernia. On examination, he had two normal testicles in scrotum, one on either side. During left inguinal exploration for hernia repair, a third undescended testicle was found incidentally, which was excised.

Bilateral polyorchidism with ipsilateral two undescended testes: a rare congenital anomaly

Polyorchidism is defined as the presence of more than two testes. This rare congenital anomaly has been reported with only 140 pathologically proven cases in the published literature to date. While triorchidism is the most common variation and generally affects the left side, bilateral polyorchidism is even rare and only seven cases of patients with four testes have been reported in the literature. There is no consensus in the literature regarding the management of supernumerary testis due to its rareness. We report such a rare case of a 20-year-old male patient, who was presented with left-sided scrotal mass and right inguinal swelling and, diagnosed as polyorchidism including four distinct testes, with two of them in left hemiscrotum and the other two testes in the right inguinal canal. The patient underwent orchiopexy for the normal looking right-sided testis, and orchiectomy for the right-sided supernumerary testis being dysmorphic and potential malignancy risk. Histopathological examination confirmed the excised tissue to be severely atrophic testicle. The patient is still following with regular self-examination and scrotal ultrasonography. Polyorchidism should be keep in mind especially for the differential diagnosis of extratesticular and paratesticular masses. Physical examination may not be sufficient, and radiologic examination can provide accurate diagnosis. Conservative, extirpative or reconstructive approaches could be performed based on individual basis by reproductive potential and location of supernumerary testis, coexistence of other disorders and suspicion of malignancy.

Triorchidism: Presenting as Undescended Testis in a Case of Indirect Inguinal Hernia

Triorchidism is the commonest variety of polyorchidism, an entity with more than two testis is an extremely rare congenital anomaly of the testis. Although excision of the abnormal testis is a safer alternative proposed, recent literature suggests more conservative approach in normal testes with watchful regular follow up to screen for malignancy. This case presented as a left inguinal swelling diagnosed as indirect left inguinal hernia. The left side testis was of smaller size (about half) with normal sperm count, morphology and motility. Intraoperatively indirect inguinal hernia was noted with supernumerary testis at deep ring in addition to normal left testis in left scrotal sac. The ectopic testis were small (2.5×2.5×1 cm) lacking epididymis and with short vas deferens. An evident normal semen analysis and varied anatomy, the decision for orchidectomy of ectopic testis was taken. The histopathological finding was consistent with arrest in germ cell development.

Report of a boy with polyorchidism and a review of current knowledge regarding this unusual anomaly

Polyorchidism is an extremely rare testicular malformation in children, and its etiology is unknown. There is an increased risk for testicular malignancy in these patients and a common association with other abnormalities, such as cryptorchidism, inguinal hernia, testicular torsion, hydrocele, and varicocele. There are insufficient data in the literature on the ideal management of polyorchidism. We report a 14-year-old boy with polyorchidism and review the current literature regarding this anomaly. Physical examination revealed a discrete, painless, left intrascrotal lump. αFP, β-hCG and LDH were normal. Scrotal ultrasound showed a well-circumscribed tissue in the left hemiscrotum measuring 2.5×2.0×1.3 cm and having the same echo-genicity as the normal testes. Color Doppler study and magnetic resonance imaging also confirmed the tissue as a third testis with its own epididymis draining to a common vas. The testis was left in situ, and the patient was managed conservatively. Polyorchidism should be considered in the differential diagnosis of all scrotal masses. The etiology of polyorchidism is thought to be accidental division of the genital ridge before 8 weeks of gestation. The cases are divided into two categories according to anatomical properties, such as having drainage to an epididymis and vas deferens. The majority of cases are mainly encountered during evaluation for the other symptoms associated. Recent evidence supports that these cases may be followed conservatively when clinical findings and imaging techniques detect no complications or suspicion for malignancy, torsion, hernia, or cryptorchidism.

Scrotal swelling in the neonate

Discovery of scrotal swelling in a neonate can be a source of anxiety for parents, clinicians, and sonologists alike. This pictorial essay provides a focused review of commonly encountered scrotal masses and mimics specific to the neonatal setting. Although malignancy is a concern, it is very uncommon, as most neonatal scrotal masses are benign. Key discriminating features and management options are highlighted to improve the radiologist's ability to diagnose neonatal scrotal conditions and guide treatment decisions. Neonatal scrotal processes ranging from common to uncommon will be discussed.

Three testicles in one hemiscrotum: an unusual presentation of polyorchidism

Polyorchidism, or more than one testicle in a hemiscrotum, is a relatively rare phenomenon. It is often associated with several other conditions, including inguinal hernia, testicular maldescent, testicular torsion, hydrocele or hypospadias. In this report, we describe a patient who presented with three testicles in one hemiscrotum, which is a highly unusual presentation for an already uncommon condition. We also review the relevant literature as it relates to the need for surveillance due to the increased risk for malignancy.

Functional supernumerary testis in a child with testicular torsion and review of polyorchidism

Histologically confirmed polyorchidism is an uncommon condition. The majority of cases are asymptomatic and associated with inguinal hernia or cryptorchidism. There are few reported cases of pediatric supernumerary testis presenting with testicular torsion. We present a case of missed torsion with incidentally detected triorchidism as well as an overview of pediatric polyorchidism.

Bilateral polyorchidism with diffuse microlithiasis: a case report of an adolescent with 4 testes

Polyorchidism is a rare congenital anomaly, with only 140 pathologically proven cases reported. Bilateral polyorchidism is far less common than triorchidism. Most cases present as a painless scrotal mass or are found incidentally during evaluation of other inguinoscrotal pathologies. We report a case of bilateral polyorchidism with 4 testes, 2 in each hemiscrotum that presented as left-sided testicular pain and hydrocele.

Triorchidism: a rare genitourinary abnormality

Polyorchidism is an extremely rare congenital anomaly which refers to the presence of more than two testicles. There are very few reports of triorchidism in a 2 year old child. Polyorchidism is usually discovered incidentally. The most common anomalies associated with polyorchidism are inguinal hernia (30%), maldescended testis (15% to 30%), testicular torsion (13%) and hydrocele (9%). A 2-year-old child was brought with bilateral undescended testis with normal milestones. Ultrasonography of scrotum and abdomen showed both the testes to be in inguinal canal. Intra-operatively, on left side - there were two testes, which belonged to Leung III class and one testis on right side. Management of polyorchidism is still controversial. The management of polyorchidism will depend upon the location, size and anatomical organisation of the testicular drainage system and the age of the patient.

Torsion of bilobed testis and biopsy-proven ipsilateral supernumerary testis in an adolescent

Testicular torsion in patients with polyorchidism is rare, with less than 20 cases being reported. Bilobed testis has only been reported once in the literature to date. We report an interesting case of polyorchidism with torsion of an ipsilateral bilobed testis. The abnormal looking bilobed infarcted testis was removed, but the smaller viable supernumerary testis was biopsied and preserved.

Incomplete unilateral polyorchidism (bilobed testicle) mimicking testicular tumour

Incomplete polyorchidism (also called bilobed testicle) is an extremely uncommon congenital anomaly. Only 3 cases of bilobed testicle were previously reported in the available literature. We describe a case of a 4-year-old boy who presented with a 6-month history of an asymptomatic scrotal mass located in the upper pole of the left testicle mimicking testicular tumour. After partial orchiectomy, macroscopic and pathological examination of the lesion confirmed the diagnosis of normal testicular tissue.

Bilobed testicle in children: diagnosis and management

Bilobed testicle is an extremely rare testicular malformation in children. It may be presumed that this condition could be an incomplete expression of polyorchidism; however, the etiology of both entities remains unknown. In this report, a 3-year-old boy presented with a right bilobed testicle mimicking a testicular tumour. Since there are insufficient data in the pediatric literature presenting the ideal management of bilobed testicles, we believe it is important to report this case to provide more information about this condition. Although rare, bilobed testis should be considered in the differential diagnosis of a testicular mass. Surgical treatment is not mandatory, and conservative follow-up may play a role.

Polyorchidism: a meta-analysis

PURPOSE

Polyorchidism is an uncommon congenital anomaly. We systematically analyzed the literature due to the contradictory data regarding this condition.

MATERIALS AND METHODS

We conducted a database search and evaluated relevant articles for the appearance, comorbidities and complications of supernumerary testes. Only cases of polyorchidism confirmed by histological examination were included in the study.

RESULTS

We found 140 cases of polyorchidism. Triorchidism was the most common type, and 6 cases of 4 testes (4.3%) were reported. Most supernumerary testes (64%, chi-square p <0.001) were drained by a vas deferens. Median patient age at detection was 17 years. Left side demonstrated predominance (64.5%, chi-square p <0.001). Most cases were found during surgery for other symptoms including inguinal hernia, undescended testicle, testicular torsion and scrotal pain. Only 16% of patients complained of an accessory mass without any symptoms. Neoplasms were found in 9 cases (6.4%), of which 8 were malignant and 1 was benign. Data available for 7 malignomas (88%) revealed that all were in cryptorchid supernumerary testes.

CONCLUSIONS

Polyorchidism is rare and is generally found during evaluation for other conditions such as inguinal hernia, undescended testis and testicular torsion. Cryptorchidism appears to be the most important risk factor for malignancy in patients with supernumerary testes. Thus, patients with nonscrotal supernumerary testes require appropriate counseling. The supernumerary testis is frequently drained by a vas deferens, implying a probable reproductive function. Decision for surgery, biopsy or orchiectomy should be based on concomitant symptoms, cryptorchidism or suspected malignancy. We provide a guideline for management based on a functional classification of polyorchidism.