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Surgical Management of Polyorchidism in a Patient With Fertility Problems

GIUSEPPE ROMANO

M. ANTONELLA BERTOZZI

COSTANZO CATUOGNO^,

From the Departments of ^* Urology and Andrology, S. Chiara Hospital, Pisa University; and Department of Urology, Jazzolino Hospital, Vibo Valentia, Italy. Deceased.

Correspondence to: Giorgio Pomara, MD (e-mail: g.pomara{at}libero.it).

Received for publication October 24, 2002; accepted for publication February 3, 2003.

Case Report

A 43-year-old man sought treatment because he was still childless after 7 years of marriage. There was no prior history of genito-urinary complaints. The mean values on 3 semen evaluations in 30 days showed a moderate asteno-oligo-spermia (16 million sperm per mL, 40% motility [5% fast forward], 3.4 mL volume). Left scrotal examination revealed 2 ovoid swellings, fixed side-to-side, homogenous in consistency, and without firm or hard areas. Color-Doppler ultrasonography suggested the presence of 2 different homolateral testes with separate blood supply. Laboratory studies, including oncological markers, were within normal limits. Further surgical exploration confirmed a complete left testicular duplication. Each of the 2 left testes, with its own epididymis and vas, was partially connected by tunica albuginea (the Figure). Biopsies, performed in both testes, revealed normal spermatogonial proliferation and normal meiotic progression up to the second spermatocyte stage. Many spermatids showed clear pyknotic degeneration, and the base membrane was lightly thickened. No signs of malignancy were present. The 2 left testes were placed in 2 different subdartoic sacs. After 10 months, the mean values on 3 semen evaluations in 30 days improved (24 million sperm per mL, 52% motility [10% fast forward], 3.2 mL volume), and the patient fathered a child.

View larger version (116K): [in this window] [in a new window]   Figure. Two homolateral left testes connected by the tunica albuginea at the lower poles.

Comment

Polyorchidism is a rare abnormality with about 100 cases reported in the literature (Mathur et al, 2002). Our case falls into the type D category of Leung's classification revised by Thum in 1991, with complete left testicular duplication. Although using high-resolution imaging one can make a certain diagnosis of polyorchidism and look for malignancy (Chung and Yao, 2002), management is still controversial, and some authors recommend orchiectomy in adults (Mathur et al, 2002). We decided not to remove the supernumerary testis so that our patient would have more testicular tissue and probably a better fertility index. It is known that elevation of testicular temperature may result in arrest of spermatogenesis, abnormal semen parameters, and sterility. Optimal scrotal temperature is maintained by a thermoregulatory apparatus consisting of the cremasteric and dartos muscle and blood vessels of the spermatic cord and of the scrotum. Additionally, the exposed surface area controls radiant heat loss. It is possible that this patient's infertility was not directly correlated to the connected left testes but, given that he had unsuccessfully undergone medical therapies before and the spermiogram improved after surgery, we can hypothesize that separation of the 2 homolateral testes had increased the heat dispersion surface with radiant heat loss, improving fertility index.

References

Mathur P, Prabhu K, Khamesra HL. Polyorchidism revisited. Pediatr Surg Int.2002; 18:449 –450.[Medline]

Thum, G. Polyorchidism: case report and review of the literature. J Urol. 1991;145:370 –372.[Medline]

Chung TJ, Yao WJ. Sonographic features of polyorchidism. J Clin Ultrasound.2002; 30:106 –108.[Medline]

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