UROLOGICAL SURVEY   ( Download pdf )

 

RECONSTRUCTIVE UROLOGY

Fournier’s Gangrene: A Review of 43 Reconstructive Cases
Ferreira PC, Reis JC, Amarante JM, Silva AC, Pinho CJ, Oliveira IC, da Silva PN
Department of Plastic, Reconstructive, and Aesthetic Surgery, Hospital de Sao Joao, Porto Medical School, Porto, Portugal
Plast Reconstr Surg. 2007 Jan;119(1):175-84

  • Background: Fournier’s gangrene is a rare and potentially fatal infectious disease characterized by necrotic fasciitis of the perineum and abdominal wall, along with the scrotum and penis in men and the vulva in women. Fournier’s gangrene is a true surgical emergency. Skin loss can be very incapacitating and difficult to repair.
  • Methods: The authors reviewed retrospectively the clinical records of a series of 43 patients with Fournier’s gangrene between the years 1985 and 2003 who, after initial treatment by the Departments of Urology and Surgery, were referred to the Department of Plastic Surgery for reconstruction. The following parameters were evaluated: age, gender, interval between onset of symptoms and diagnosis, clinical symptoms, lesion site, results of bacteriologic cultures, cause and predisposing factors, treatment and reconstructive procedures, length of hospital stay, and outcome.
  • Results: The mean patient age was 56.6 years. Fifteen patients (34.9 percent) had diabetes mellitus. The cause of Fournier’s gangrene was found in 32 patients (74.4 percent). The most common presentation was scrotal swelling, and scrotal involvement was found in 40 cases (93.0 percent). All of the patients underwent surgical debridement, and several reconstruction techniques were used. The mean length of hospital stay was 73.6 days. Two patients died.
  • Conclusions: Management of this infectious entity should be aggressive. Several techniques that are used to reconstruct the lost tissue have shown good results. The superomedial thigh skin flap has proven to be a reliable method of resurfacing large scrotal defects. Reconstructive surgery makes the return to a normal social life possible in many cases.

  • Editorial Comment:
    This long-term retrospective study underlines the importance of Fournier’s gangrene, which is a rare but very lethal emergency that should be diagnosed early and treated aggressively. The article updates the clinical picture with the required knowledge to efficiently handle these cases.
    There is no predicting age, but predisposing factors such as diabetes, colorectal disorders and/or alcohol abuse in addition to hypertension, obesity and cigarette consumption are frequently seen in the constellation with Fournier’s gangrene. The authors found a predominant involvement of the scrotum with scrotal swelling or scrotal lesions in more than 90% of male cases. Surprisingly, however, Fournier’s gangrene was also seen in 21% of females (1).
    After hemodynamic stabilization, an aggressive surgical debridement is a must with corresponding infusion therapy. Frequently the repeated debridement is necessary before a reconstruction can be planned. In 80% of the cases, the cause of the gangrene was polymicrobic with Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa being the predominantly found microbial. In addition, the increasing role of methicilin resistant S. aureus (MRSA) in genitoperineal infection needs to be stressed (2).
    Most of the time an orchiectomy or penectomy was not necessary. In the author’s opinion, the superomedial skin flap was the most reliable method of reconstruction in large scrotal defects after formation of healthy granulation tissue. Fasciocutaneous or musculocutaneous flaps were performed only in special cases. For functional, physiological and psychological reasons, the reconstruction of the scrotum is essential and may require a multi-modal approach instead of split- and full-thickness skin grafts, which can be used only in minimal lesions.
    With the regimen outlined in this paper, only one out of the 43 patients died due to multiple organ failure. Others have reported a mortality rate up to 67% (1) whereas a decreased mortality rate of 22.8% was achieved by using the Fournier’s Severity Index (3).
    From this and other reports it can be concluded that the earliest possible diagnosis and aggressive therapy, repeated surgical debridement, and combined aggressive broad-spectrum antibiotic coverage keeping in mind the increasing role of MRSA decrease morbidity and mortality of Fournier’s gangrene. The reconstructive surgical approach helps to restore physiological function of external genitalia and thus a return to a normal social life.


References

1. Norton KS, Johnson LW, Perry T, Perry KH, Sehon JK, Zibari GB: Management of Fournier’s gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg. 2002; 68: 709-13.
2. Kalorin CM, Tobin EH: Community associated methicillin resistant Staphylococcus aureus causing Fournier’s gangrene and genital infections. J Urol. 2007; 177: 967-71.
3. Ersay A, Yilmaz G, Akgun Y, Celik Y: Factors affecting mortality of Fournier’s gangrene: review of 70 patients. ANZ J Surg. 2007; 77: 43-8.


Dr. Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany