Abstract

Testicular duplication, supernumerary testis or most commonly known as polyorchidism constitutes an especially rare congenital anomaly of the genitourinary tract. We report a 10-year-old male patient presented to our clinic with a visible as well as palpable left scrotal mass. With the view to determining whether the surgical excision of the additional testis or its monitoring by imaging is more preferable, we took many factors into consideration, including patient’s comorbidities, testicular biopsy’s outcome as well as the classification of the extra testes. The diagnosis of the additional testis was confirmed by histopathology and underline the need to maintain a high index of suspicion.

Keywords: Testicular Duplication; Triorchidism; Polyorchidism; Pediatric; Accessory Testis; Genitourinary Tract

Introduction

Testicular duplication, supernumerary testis or most commonly known as polyorchidism constitutes an especially rare congenital anomaly of the genitourinary tract, with a few cases in the international literature [1]. In the vast majority of cases, it is presented as triorchidism [2]; in other words, the presence of an additional testis either inside (66%) or outside the scrotum. Regarding the extra scrotal sites of detection, these may be inguinal (23%) and abdominal (9%) [3]. The side which is affected the most is the left hemiscrotum (66%) [4,5], which is also the case with our patient. Since triorchidism can be rather unlikely to occur, amplitude of other syndromes come to mind and rank the highest places in the differential diagnosis, leading to a misdiagnosis of the former. Amongst them, we may find varicocele, hydrocele, inguinal hernia, cryptorchidism, epididymitis, testicular neoplasm [3,6] to name only a few. In the current case report, we present the imaging findings in triorchidism along with the contribution of histopathological analysis to the diagnosis, without omitting to mention the treatment of choice.

Case Presentation

A 10-year-old male patient presented to our clinic with a visible as well as palpable left scrotal mass. The lump had appeared approximately a year prior to the clinical examination, without any complaint of discomfort or even pain on behalf of the patient. Furthermore, the size of the mass maintained a stable course since its detection. The boy had not a relevant past medical history and had not undergone any previous abdominal or inguinal surgery. During the clinical exam, we did not encounter any sign of edema or haemorrhage on the left side and any pathological findings on his right hemiscrotum. Moreover, there was no evidence of hernia or lymphadenopathy in inguinal examination. The patient did not report lack of appetite or presence of fever, nor did his parents mention any alteration of his bowel or urinary habits. In the first place, his laboratory findings did not correspond with an active inflammation since all relevant markers were within the normal range, eliminating epididymitis as a possible underlying cause. The values of Hct and Hgb which fluctuated just below their lowest normal values merely set the suspicion for a mild type of anemia , whereas the perfectly normal value of platelets did not predict any haemorrhagic predisposition. In addition, all cancer biomarkers were normal thus, the possibility of a malignancy was significantly low in the differential diagnosis. Thereafter, an ultrasound scan was performed on the patient, which showed the presence of what was presumed to be a left epididymal cyst. Nevertheless, histopathological analysis is nowadays the most sufficient and definitive diagnostic tool so we proceeded with a biopsy with the prospect of identifying the consistency of this engorgement (Figures 1,2).

Figure 1: The tubular diameter of the seminiferous tubules is smaller than normal. There is slight increase of intratubular fibrosis.

Figure 2: There is slight increase of intratubular fibrosis. Increased number of Sertoli cells in the seminiferous tubules.

The results of the biopsy indicated macroscopically a grey small tumour with a diameter of 0.4 cm and microscopically, with the consistency of an atrophic testis. As it was anticipated, the tumour was smaller than the normal unilateral one, both of which were composed of identical testicular tissue. Hence, its coevaluation along with genetic, imaging and clinical assessment of the patient’s genitourinary system was suggested. For every one of these procedures, an informed consent by the parents was mandatory. As far as the management strategy is concerned, we opted for the surgical removal of the accessory testis, as depicted in Figures 3 and 4, since the latter had its own epididymis but shared a common vas deferens with its neigh-boring testis. There were no postoperative complications and the incision healed quickly and with a satisfying cosmetic appearance.