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Fournier???s Gangrene: A Review of 43 Reconstructive Cases
Abstract
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.
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.
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.
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.
... Chart 1. Authors, type of study, and flaps used for wound reconstruction after Fournier's gangrene in the selected articles. Ferreira et al. 18 37 Retrospective Local advancement flaps = 9 Superomedial/thigh flaps = 28 ...
... Flaps can present with complications, such as necrosis, dehiscence, and hematomas. Dehiscence is related to tension in the suture planes, necrosis to the poor blood supply to the vascular pedicle of the flap, and hematoma to inadequate hemostasis [17][18][19][20][21][22][23][24][25][26][27][28] . ...
... The scrotal advancement flap offers a good aesthetic result and fulfills the principle of replacing with similar skin, being recommended for scrotal skin loss of up to 50% of the total scrotal surface. The benefits of this method include good skin quality, elasticity, and the presence of the dartos muscle 17,18,[22][23][24] . ...
Introduction
Fournier’s gangrene is characterized by tissue necrosis, which requires treatment employing debridement and antibiotics with wounds of varying sizes. The objective is to standardize the surgical techniques of reconstructions with flaps used to treat wounds after Fournier’s gangrene.
Method
A study was conducted by searching the PubMed/Medline, SciELO, and LILACS databases.
Results
In wounds with skin loss of 25% to 50%, a local advancement cutaneous flap or a pudendal flap from the thigh was used; in wounds, greater than 50%, a superomedial thigh flap or myocutaneous flap from the gracilis muscle was used, with the aim of to enable proper reconstruction.
Conclusion
Advancement and pudendal thigh flaps were used for wounds with up to 50% loss of scrotal skin substance, while the myocutaneous gracilis flap and supero-medial flap of the thigh were indicated for wounds with more than 50% of the total scrotal surface affected, after Fournier gangrene.
Keywords:
Fasciitis, necrotizing; Fournier gangrene; Surgical flaps; Perforator flap; Myocutaneous flap; Reconstructive surgical procedures
... Fournier's gangrene is a debilitating, rapidly progressive, and aggressive form of necrotizing fasciitis of the genital and perineal tissues that requires urgent control and treatment. The lesion should be excised in width and depth up to healthy looking tissue with normal blood supply usually in more than one session of surgical debridement, as the extent of necrosis is often broader than what could be initially anticipated [1][2][3]. Broad-spectrum empirical antibiotic treatment should be administered against all the possible causative bacteria of the gangrene with Staphylococcus, Enterococcus, Escherichia coli, Pseudomonas, and anaerobe strains being the most frequent isolates. Blood, tissue, and urinary cultures should be obtained for the etiology to be determined and targeted treatment to be delivered based on sensitivity tests [1,3]. ...
... Broad-spectrum empirical antibiotic treatment should be administered against all the possible causative bacteria of the gangrene with Staphylococcus, Enterococcus, Escherichia coli, Pseudomonas, and anaerobe strains being the most frequent isolates. Blood, tissue, and urinary cultures should be obtained for the etiology to be determined and targeted treatment to be delivered based on sensitivity tests [1,3]. ...
... Blood tests revealed normal hemoglobin concentration and platelet count but markedly elevated white blood cells (23 × 10 3 /µL, reference range: 4.5-11 × 10 3 /µL), with 86% neutrophilic type. Serum electrolytes 1 1 1 1 1 and liver biochemistry were normal, while serum creatinine, urea, and glucose level were all elevated (2.4 mg/dL, 94 mg/dL, and 180 mg/dL, respectively). The emergency non-contrast CT scan of the upper and lower abdomen and pelvis was indicative of infection of the base of the penis, the inguinal area, the scrotum, and the perineum (but it was not infiltrating the anal ring) with gas and fluid collection (Figures 1, 2). ...
Fournier's gangrene is a urologic emergency manifested as an aggressive form of necrotizing fasciitis. Co-infection of Fournier's gangrene with COVID-19 might have catastrophic sequelae. We report a case of a 69-year-old male patient, unvaccinated against coronavirus, was obese, and with type 2 diabetes diagnosed with Fournier's gangrene. Apart from administration of piperacillin/tazobactam and clindamycin, the patient underwent surgical debridement four hours after his presentation. Postoperatively, the PCR test for COVID-19 was proved to be positive. The patients develop septic shock necessitating the delivery of dopamine, supplemental oxygen, and thromboprophylaxis. On the seventh postoperative day, left testicular ischemia was developed and ipsilateral orchiectomy was performed. After his full recovery from an in-hospital infection by Acinetobacter baumannii, the patient was transferred to the plastic surgery department. The prompt surgical debridement has likely counterbalanced the health risk originated from COVID-19 infection, contributing to the patient's full recovery. Testicular ischemia is a very rare condition in necrotizing fasciitis of the genital and perineal space and it could be attributed primarily to the thrombotic nature of coronavirus. Due to the assault of multiple organs and systems, a medical board consisting of urologists and other medical specialties substantially contributed to the favorable outcome.
... Initial treatment of Fournier's gangrene includes wide and radical debridement of infectious tissues to control the infection. Hence, most cases require perineoscrotal reconstruction after primary treatment [1,2]. However, Fournier's gangrene rarely extends upward into the high intermuscular plane, especially into the supralevator plane in the anal region [3], because the fascial planes of the sphincteric area are distinguished from the periscrotal area. ...
... A 63-year-old non-insulin-dependent diabetic male sought evaluation in our emergency room for severe pain and swelling of the scrotum. He had experienced painful discharge around the anus for 1 week. An abdominal computed tomography scan revealed air collection in the scrotum, penis, and perineum, consistent with a diagnosis of Fournier's gangrene (Fig. 1). ...
... Fournier's gangrene is a soft tissue infection around the perineum that rapidly spreads into surrounding tissues [1,2]. Delays in diagnosis are common, owing to vague symptoms, resulting in sepsis and a high mortality rate [4]. ...
Fournier’s gangrene, a soft tissue infection which is aggressive and sometimes lethal, often passes through deep fascial planes of the penis, scrotum, perineum, and lower abdomen; however, it rarely extends upward into the high intermuscular plane. We managed a rare case of Fournier’s gangrene with a high intersphincteric abscess from a perianal infection that resulted in a large defect in the anus and inferior aspect of the scrotum. A perforator-based island flap for the post-debridement defect was performed successfully. The perforator was selected near the defect along the lateral sacral border; the border of the flap design was adjacent to the defect, thus providing a sufficient angle of rotation near the pedicle with minimal dissection. Remnant undissected tissues around the pedicle prevented postoperative vascular complications. Additionally, the distal part of the flap design was elongated to the gluteal sulcus to be harvested as a very thin flap. This study suggests a perforator-based island flap as a secure and convenient option for covering a large defect involving the perianal region and inferior aspect of the scrotum.
... However, the segmental blood supply of the flap means that viability can be unpredictable in contaminated wounds although it is a generally resilient flap. 13,14 Another type of myocutaneous flap is the vertical rectus abdominis flap, where the muscle is harvested along with its pedicle, the deep inferior epigastric artery ( Figure 6). The easily harvested flap is large and long with a low incidence of necrosis. ...
... Some argue that flaps have a superior cosmetic outcome when compared to skin grafting. 5,11,14,22 However, others have found the thicker nature of local flaps can lead to cosmetic concerns as it does not resemble a thin, pliable scrotum. 25 In more extensive defects with an absent tunica vaginalis, fasciocutaneous flaps (anteromedial thigh, anterolateral thigh, pudendal artery thigh flaps) or myocutaneous flaps (gracils and rectus abdominis flaps) should be used. ...
... 20,24 Studies have shown the superomedial thigh flap to be an excellent option for scrotal defects, with the potential complication of wound dehiscence. 14,26 Pudendal and anterolateral thigh flaps also have excellent outcomes in the literature, with good flap survival, Figure 9. An example where there was preservation of the distal penile shaft, with a split-thickness skin graft placed on the abdomen, the testicles located in groin pockets and a colostomy formed (photo 1). ...
Introduction
Fournier's gangrene is a urological emergency, comprising of type I necrotizing fasciitis resulting in anatomic defects affecting the perineum, perianal region, and external genitalia in both men and women, often requiring reconstruction.
Objectives
The aim of this article is to provide a comprehensive review of the different reconstructive techniques for Fournier's gangrene.
Methods
A literature search was performed on PubMed with the search terms “Fournier”s gangrene” “genital reconstruction” and “Fournier's gangrene phalloplasty.” The European Association of Urology's guidelines on Urological infections were also consulted for recommendations.
Results
Reconstructive procedures include primary closure, scrotal advancement flaps, fasciocutaneous flaps, myocutaneous flaps, skin grafts, and phalloplasty. There is insufficient evidence to support that flaps lead to better outcomes than skin grafts, or vice versa, particularly for scrotal defects. Both techniques have been shown to have satisfactory aesthetic results, with good skin color match and natural scrotal contour. With regards to phalloplasty, there is a lack of data specifically relating to Fournier's gangrene, as most articles were addressed toward gender affirmation surgery. Furthermore, there is a lack of guidelines in both the immediate and reconstructive management of Fournier's gangrene. Lastly, the outcomes reported following reconstructive surgery have been objective rather than subjective, meaning that patient satisfaction was rarely recorded.
Conclusion
Further research is required in the field of reconstructive surgery specific to Fournier's gangrene, which should also take into consideration patient demographics and subjective reports regarding cosmesis and sexual function.
Michael P, Peiris B, Ralph D, et al. Genital Reconstruction following Fournier's Gangrene. Sex Med Rev 2022;XX:XXX–XXX.
... Infection is most often polymicrobial, arising from the colorectal or urogenital tracts [1,2]. The single greatest predisposing factor for disease development is diabetes mellitus, found in up to 66% of affected patients [2][3][4]. Other common comorbidities include alcoholism and obesity [2][3][4]. ...
... The single greatest predisposing factor for disease development is diabetes mellitus, found in up to 66% of affected patients [2][3][4]. Other common comorbidities include alcoholism and obesity [2][3][4]. Despite recent advances in medical management, Fournier's gangrene continues to carry a substantial risk of mortality, as high as 90% with any delay in care [1][2][3][4][5][6]. ...
... Other common comorbidities include alcoholism and obesity [2][3][4]. Despite recent advances in medical management, Fournier's gangrene continues to carry a substantial risk of mortality, as high as 90% with any delay in care [1][2][3][4][5][6]. Therefore, early recognition and treatment with broad-spectrum antibiotics and surgical debridement are critical [1,3,6]. ...
We describe the case of a 43-year-old male diagnosed with acute myeloid leukemia complicated by Fournier's gangrene. Multiple debridements led to the complete effacement of the scrotum, with 360 degrees of exposed testes and a narrow base of suspension. It was decided to reconstruct the scrotum using bilateral gracilis muscle rotational flaps, followed by split-thickness skin grafting from the thigh. The gracilis muscle as a donor flap allowed for the protection and support of the testes and suspensory tissue while achieving an aesthetically pleasing result that resembled the normal scrotum. We hope providers will consider this reconstructive method in future patients who present with similar extensive effacement of the scrotal tissue.
... The main types are the scrotal and preputial flaps, fasciocutaneous thigh flaps, and myocutaneous flaps. Use of scrotal and preputial flaps has been described mostly in defects that encompass less than 50% of the scrotal area; these are technically simple and show good cosmetic results (15). Fasciocutaneous thigh flaps include the superomedial thigh flap, described by Hirshowitz et al. in 1980, the medial thigh fasciocutaneous flap, described by Hallock in 1990 (16) and the pudendal flap (17). ...
... Fasciocutaneous thigh flaps include the superomedial thigh flap, described by Hirshowitz et al. in 1980, the medial thigh fasciocutaneous flap, described by Hallock in 1990 (16) and the pudendal flap (17). This kind of fasciocutaneous flap offers scrotum coverage without sacrificing muscular function and shows acceptable esthetic results with the possibility of donor site primary closure (15,18). Other authors have described myocutaneous flaps, including gracilis and Bilateral SCIP flaps to large scrotoperineal defect reconstruction rectus abdominis myocutaneous flaps; however, these have a bulky appearance at the perineoscrotal level limiting its uses (15,17,19). ...
... This kind of fasciocutaneous flap offers scrotum coverage without sacrificing muscular function and shows acceptable esthetic results with the possibility of donor site primary closure (15,18). Other authors have described myocutaneous flaps, including gracilis and Bilateral SCIP flaps to large scrotoperineal defect reconstruction rectus abdominis myocutaneous flaps; however, these have a bulky appearance at the perineoscrotal level limiting its uses (15,17,19). ...
Background: Scrotoperineal defects reconstruction can be related to multiple etiologies, being Fournier’s gangrene one of the most important etiologies due to its rapidly progressive nature and high mortality rates. Therefore, new reconstruction techniques have been developed and analyzed over the past few years to achieve good functional and esthetic results, among these techniques are the perforator flaps. Objective: Presenting this case, we want to prove that using bilateral SCIP (superficial circumflex iliac artery perforator), flaps can be a satisfactory option for reconstruction of scrotoperineal defects, without major postoperative complications and adequate functional and esthetic results. Design: This article describes the use of the bilateral SCIP flaps as a reconstructive alternative in scrotum and perineum large defects. Results: SCIP flaps can achieve good results in the reconstruction of large scrotoperineal defects at the functional and esthetic levels, with minimum morbidity in the donor site. Discussion: Multiple alternatives for perineoscrotal defects reconstruction have been described in the literature. The proposed surgical treatment algorithms depend on various factors such as the location and extension of the compromised areas. Conclusions: The discussed SCIP flap proves a very good alternative in the analyzed cases and can be used in a unilateral or bilateral way depending on the extension of the defect to be reconstructed.
... Parkash et al 6 43 Retrospective IV Scrotal advancement flap = 40; skin graft = 3 Minor scrotal wound dehiscence = 4 Morris et al 7 18 Retrospective IV Skin graft = 6; skin flap = 12; tissue adhesive = 18 Flap wound breakdown = 1 Ferreira et al 8 43 27 17 Retrospective IV NA NA Saffle et al 28 30 Retrospective IV NA NA Gürdal et al 29 28 Retrospective IV Skin graft = 14 NA Wang et al 30 24 Retrospective IV Skin graft = 15 None Omisanjo et al 31 11 Retrospective IV NA NA Khanal et al 32 14 Retrospective IV Bilateral pudendal flaps = 14 Flap necrosis = 1 Dadaci et al 33 29 Retrospective IV Limberg thigh flaps = 29 Dehiscence and seroma = 4 Boughanmi et al 34 18 Retrospective IV N/A N/A Agwu et al 35 47 From the secondary intention, 1 patient underwent flap coverage of urinary fistula Chang et al 67 13 Retrospective IV Local flap = 6, direct suture = 7 N/A Yucel et al 68 25 Retrospective IV Primary closure or skin graft N/A Hong et al 69 20 75 48 Retrospective III Skin grafting or primary wound closure N/A Milanese et al 76 6 ...
... Thick split-thickness skin grafts were preferred to minimize contractures. 8 Full-thickness skin grafts were used in four patients for tubed urethroplasty. 8 Importantly, when skin grafting is needed to cover defects in the testicles, the tunica vaginalis needs to be intact; in its absence, skin grafting will not be successful 13 (Fig. 4). ...
... 8 Full-thickness skin grafts were used in four patients for tubed urethroplasty. 8 Importantly, when skin grafting is needed to cover defects in the testicles, the tunica vaginalis needs to be intact; in its absence, skin grafting will not be successful 13 (Fig. 4). This procedure is considered a good option to keep morbidity low when specialized care is not available. ...
Background:
Fournier's gangrene is a fulminant disease. If diagnosed and treated early, mortality can be minimized, but morbidity can still be important with extensive soft tissue defects affecting form and function. We aimed to perform a comprehensive review and provide the current evidenced-based management to treat this condition.
Methods:
A review was conducted to identify relevant published articles involving Fournier's gangrene in PubMed on September 8, 2021. Search keywords included "{[(Fournier's gangrene) AND (reconstruction)] OR [Fournier's gangrene]} AND [(repair) OR (management)]."
Results:
A total of 108 articles met the inclusion criteria. The comorbidities most frequently associated included diabetes, hypertension, and obesity. Pillars of treatment involve urgent debridement, fluid resuscitation, IV antibiotics, and reconstruction. Several variables must be considered, including time to debridement, duration of antibiotics, debridement, and an individualized approach to choose a reconstructive option. Skin grafts and multiple types of flaps are commonly used for reconstruction.
Conclusions:
Treatment of Fournier's gangrene should be initiated as early as possible. Surgeons' expertise, patient preference, and resources available are essential factors that should direct the election of reconstruction.
... Necrosis progresses rapidly, and there is 3%-67% mortality. [8] Although it was described by Fournier in1883 as a necrotizing infection in a healthy male patient without any cause, [9] the current definition of the disease is quite different, i.e., a necrotizing infection due to a specific cause in an old patient with comorbidity. [10] An initiating cause such as colorectal disease, perianal skin infection, or urinary infection is seen in most patients. ...
... Again, The most common comorbidity is diabetes mellitus. [5,8] Diabetes mellitus was also the most common comorbidity in our study. As the disease progresses rapidly, treatment includes debridement of the necrotized tissues, broadspectrum antibiotic therapy preferably according to culture sensitivity, and fluid replacement therapy. ...
... The mean time from disease occurrence to defect reconstruction is 33-35 days. [5,8] This period involves clinical stabilization of the disease and wound preparation for reconstruction. In the present study, the average hospital stay following reconstruction is 5 days. ...
Fournier's gangrene is a necrotizing fascitis of the perineum and external genitalia,. It involves the perianal area and scrotum. It progresses quickly. Management involves adequate wound debridement, broad-spectrum antibiotic and fluid replacement therapy. Reconstruction can be planned secondarily after clinical stabilization.
... Infection extends rapidly along Colles' and Dartos fascia and via Scarpa's fascia may involve the abdominal wall [18,22]. It has been noted that in Fournier's gangrene, the resultant microvascular thrombosis with subsequent dermal necrosis is due to anaerobes which release enzymes such as collagenase, heparinise along with platelet aggregation and complement fixation induced by aerobes. ...
... Complete removal of all necrotic tissue including skin, subcutaneous tissue and fascia, until wellvascularised tissue remains should be the aim of wide surgical debridement and this may require multiple sittings to achieve. Since testis has independent blood supply directly from the abdominal aorta via testicular artery, it remains unarmed and orchidectomy is not necessary [22]. Treatment with hyperbaric oxygen for Fournier's is debatable as its use in any other wound management and may support surgical debridement but not second it. ...
... Defects involving more than 50% of the scrotum then skin grafting or pudendal thigh flap are wise choices [19,27]. In cases of combined scrotal and perineal defects pudendal thigh flap, anterolateral thigh flap, superomedial thigh flap or gracilis muscle flaps can be used [19,22]. With advancement in wound management cases treated successfully using dermal regeneration templates have been reported [26]. ...
Background: Fournier's gangrene is a synergistic necrotizing fascitis of the external genitalia and perineal tissues that can be fatal. Young men are the most typically affected, however it can also
affect women and children. The use of broad spectrum antibiotics and surgical intervention with serial wound debridement is the main stay of treatment and critical determinant of prognosis.
It's a difficult undertaking to rebuild a soft tissue defect after it's been debrided. The goal of this study is to evaluate the surgical reconstruction methods of soft tissue defects due to Fournier's gangrene.
Methods: This prospective study included all patients with necrotizing fascitis of external genitalia and perineum, irrespective of age and gender presenting to our hospital. Age, gender, aetiology,
predisposing variables, clinical characteristics, defect location, type of bacterial flora, reconstructive treatment performed, length of hospital stay, post-operative pain, patient satisfaction, and death, if any, were all investigated. The technique chosen was based on the severity of the defect, the availability of local tissue, and the patient's preferences.
Results: 31 patients underwent reconstructive procedures. The participants ranged in age from 4 to 74 years old (mean 38.5). Pain, scrotal swelling, and fever were the most prevalent symptoms. Urogenital disorders were the most common cause. 10 patients
were treated by split-thickness skin graft, 5 by secondary suturing, 2 by unilateral superomedial thigh flap, 4 by bilateral superomedial thigh flap, 5 by tensor fascia lata flap, 2 by medial thigh V-Y advancement flap, 2 with perineal artery flap and one case healed by secondary intention
Conclusion: This study reveals that the mainstays of treatment are earlier presentation, early diagnosis, and intervention with debridement and suitable antibiotics. Except in one case, soft tissue
defects caused by wound debridement required surgical reconstruction, reducing morbidity, hospital stay, and patients' return to normal life.
... 65 This technique should be avoided in larger scrotal defects as in these cases the closure is under increased tension resulting in a larger risk of flap failure. 65 Split-thickness skin grafting and thigh flaps are described in the management of larger defects, 66 with graft loss, infection, scarring, adhesions, dehiscence, unacceptable cosmesis, and reduced sensation being recognised complications. 5,[64][65][66][67] FG patients are managed with extensive debridement of fascia and soft tissues, which can result in a large dead space in the perianal region. ...
... 65 Split-thickness skin grafting and thigh flaps are described in the management of larger defects, 66 with graft loss, infection, scarring, adhesions, dehiscence, unacceptable cosmesis, and reduced sensation being recognised complications. 5,[64][65][66][67] FG patients are managed with extensive debridement of fascia and soft tissues, which can result in a large dead space in the perianal region. Anatomical dead spaces can reduce the efficacy of antimicrobial therapy and result in a higher chance of failure of the reconstruction by providing an environment for bacterial colonisation and chronic inflammation. ...
This article aims to provide a practical guide for patient management and an overview of the predictive scorings for Fournier’s gangrene (FG) that are available to aid clinicians. A literature was performed reviewing currently used scoring systems for FG and presenting a practical guide for its management based on the available evidence. There are four specific scoring systems available for the assessment of FG although few other non-specific and generic tools also exist. These specific tools include Laboratory Risk Indicator for Necrotizing Fasciitis, Fournier’s Gangrene Severity Index, Uludag Fournier’s Gangrene Severity Index, and Simplified Fournier’s Gangrene Severity Index and help calculate expected mortality. Our proposed algorithm covers primary assessment, resuscitative interventions, initial investigations, urgent care, post-operative care, and long-term follow-up. The management of the FG patient can be divided into initial resuscitation, surgical debridement, ongoing ward management with antibiotic therapy, wound reconstruction, and long-term follow-up. Each facet of care is vital and requires multidisciplinary team expertise for optimal outcomes. Whilst mortality continues to improve, it remains significant, reflecting the severe and life-threatening nature of FG. More research is certainly needed into how this care is individualised, and to ensure that long-term outcomes in FG include quality of life measures after discharge.
... cuerpo del pene requieren: reparación quirúrgica libre de tensión que permita una longitud suficiente, piel adecuada para erecciones sin restricciones que permita una función sexual aceptable, sensibilidad protectora para evitar la degeneración crónica de la piel, capacidad de vaciamiento espontáneamente en bipedestación de los cuerpos cavernosos, minimizar al máximo la pérdida de tejido, mantener un grosor del cuerpo del pene aceptable, preservar la micción voluntaria, evitar retracción cicatricial y presentar una apariencia estética aceptable. 3 El cuerpo del pene está compuesto por piel, fascia de Colles, fascia de Buck, vasos y nervios superficiales dorsales, túnica albugínea, tejido eréctil compuesto por cuerpos cavernosos en pares y el cuerpo esponjoso alrededor de la uretra; las quemaduras en esta área anatómica ocasionan graves secuelas funcionales y estéticas. 4 El cirujano plástico que se enfrenta a este escenario clínico debe tener claros los objetivos reconstructivos y enfocarse en lograr una reconstrucción exitosa con la piel y tejido disponible después del desbridamiento. ...
... 2 Algunos otros grupos quirúrgicos reportan experiencia de 15 años, en la realización de injertos de piel de espesor parcial para la reconstrucción genital masculina con resultados exitosos para lesiones de múltiple etiología. 3 Debemos tener presente que el injerto de piel de espesor parcial o total es una técnica quirúrgica sencilla, relacionada frecuentemente con la contracción secundaria del injerto y dificultad para la erección. 4 En el segundo caso clínico se realizó un colgajo escrotal que permitió una cobertura cutánea adecuada con piel de características idénticas a la lesionada y sin dejar defecto cutáneo residual. ...
... A síndrome de Fournier (SF) foi descrita em 1883, por Jean Alfred Fournier, correspondendo a uma fasceíte necrotizante localizada no períneo, partes moles e parede abdominal inferior, de evolução rápida e potencialmente fatal. Inicialmente descrita como sem agente etiológico definido, hoje, a gangrena de Fournier tem sido amplamente estudada, e trabalhos recentes identificaram causas urológicas ou colorretais como as predominantes neste cenário, bem como determinados fatores predisponentes -diabetes mellitus, obesidade (1,2). ...
... Seu tratamento consiste em estabilização clínica do paciente, debridamentos amplos e antibioticoterapia adequada. Após este processo inicial, devido à perda tecidual extensa, a grande maioria destes pacientes necessita de reconstruções perineais, uma vez que os danos, não só estéticos, mas também funcionais são notáveis (1,2). Para isso, retalhos locais de coxa ou glúteo, por exemplo, podem ser empregados. ...
Introdução: A síndrome de Fournier é uma infecção multi bacteriana que acomete principalmente a região perineal; seu tratamento inclui estabilização clínica do paciente, antibioticoterapia ampla e múltiplos desbridamentos. Devido a extensa perda tecidual, se faz necessária a reconstrução da região, sendo a enxertia de pele parcial uma boa alternativa. Objetivo: apresentar uma possibilidade ao uso de retalhos - menos agressiva - na reconstrução perineal. Métodos: Apresentamos dois casos de enxertia de pele parcial em região escrotal, após preparação do leito receptor com a confecção de bolsa de curativo de petrolato não aderente. Conclusão: Conforme descrito por Morey et al., a enxertia de pele parcial em bolsa escrotal é uma alternativa funcional e segura para alguns casos. Embora não seja o padrão ouro, apresenta-se como uma opção efetiva e de baixo custo.
... Study have showed that the interval from the initial symptoms to skin gangrene is 5.1 ± 3.1d, and about three quarters of cases were misdiagnosed. 42,66 A population-based longitudinal study found the prodromal period of FG before diagnosis was about 21-day and nearly 50% of the 8098 patients got a symptomatically similar diagnosis (such as scrotal swelling, cellulitis and genital pain), which resulted in diagnostic delay. 67 Early diagnosis of FG patients without risk factors and inducing conditions is very difficult, which require clinician to sufficiently understand the early manifestations. ...
... As the infection continues to spread along the fascia plane at the speed of 1 inch/h, the erythema color become deepen and bullae appear. 16,31,66,69,70 Because of the local nerve injury, the pain in the lesion is reduced. When combined with anaerobic infection, subcutaneous twisting and malodorous purulent drainage may occur, and the final skin manifestation is gangrene. ...
Fournier’s gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% – 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier’s gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.
... Because the blood flow of the testicles and spermatic cords is provided by different source vessels, they are mostly unaffected. 13 In this case series, rashes were the most prominent finding. After the appearance of the first symptoms of FG, 2 phases have been defined in the process leading to the invasion phase: fulminant progression (necrosis phase) and tissue regeneration (spontaneous restoration phase). ...
... 19 It provides sensation to the flap with branches coming from the ilioinguinal and genitofemoral nerves. 13 Femoral and obturator nerves innervate the skin sensation of the distal part of the skin island in the flap plan area. Therefore, enlarging the flap distally will reduce the sensory ability in the flap. ...
Background:
Fournier gangrene (FG) is a necrotizing fasciitis involving perianal and abdominal regions. It progresses quickly and requires urgent intervention. With the use of vacuum-assisted closure (VAC) treatment applied during clinical follow-up and the use of superomedial thigh flap in the region, the treatment is completed with an effective, functional, and rapid approach. This study examines the clinical details of this method for reconstruction.
Methods:
The study included 15 patients who underwent superomedial thigh flap in VAC treatment reconstruction for tissue defect after FG debridement from 2016 to 2020. The patients were examined in the form of clinical evaluation with hospital admission and surgical evaluation in the postop process.
Results:
In patients with wound maturation and sufficient granulation, superomedial thigh flap application followed by VAC treatment soon after shortened the operation time, shortened the postop drain time, and provided effective treatment of dead space. An aesthetic and functional result was obtained with the proximity of the flap to the area. In addition, due to the sensory branches present in the flap, a sensory result was obtained according to the ratio of flap size.
Conclusions:
Superomedial thigh flap provides a practical, effective, and fast solution to the tissue defect that occurs after FG debridement. Effective results can be obtained when combined with VAC therapy.
... Therefore, reconstruction with split-thickness skin grafts often leads to graft loss, making them an option only for small defects. 1 In our proposed method, since the scrotum reconstruction is performed with the patient's scrotal tissues, an original scrotal appearance that can protect against trauma is obtained and there is no donor site morbidity. ...
... 11 Flap procedures have disadvantages such as longer operating time and are associated with higher morbidity and limited donor sites. 1,11,13,15 Various flap modifications have been used to cover in the literature, including local advancement flaps, scrotal flaps, and multiple musculocutaneous fasciocutaneous flaps and perforator flaps. [16][17][18][19][20][21][22][23][24][25] In our study, we aimed to use native contracted scrotal flaps for reconstruction. ...
Journal of Reconstructive Urology Fournier's gangrene is the progressive necrosis of the urogenital region. Necrosis of the skin starts with polymicrobial infection and spreads rapidly and leads to life-threatening infection with up to 67% death rate. 1 Urgent surgical intervention and aggressive debridement are recommended for stopping this dramatic progression. 2 This generally results in a tissue defect to be reconstructed. Exposed scrotal tissue ABS TRACT Objective: Fournier's gangrene is an insidious disease that occurs in the scrotal, perianal, and genital regions where aerobic and anaerobic bacteria form micro thromboses, causing tissue necro-sis and extending to the fascia and spreading to the trunk and extremities. This disease, which is more common in male patients, patients with diabetes mellitus, immunocompromised patients, and those undergoing surgical procedures has high morbidity and mortality. We present the scoring incision of scrotal flaps that we apply in our clinic and the approximation suture technique with appropriate tension. Material and Methods: A study was conducted between January 2016 and July 2021; patients whose primary surgical de-bridement procedures were terminated after Fournier's gangrene were hospitalized in our clinic to close their defects. The study examined data such as mean age, defect size and localization, accompanying diseases, reproducing microorganisms, duration of surgery, duration of hospitalization, the healing time of wounds, and complications. Results: The mean age of the patients was 61.1 years, and the most common comorbidities were diabetes mellitus and respiratory tract disease. Beta-hemolytic streptococci were the most prolific microorganism. The defects were closed in 4-7 weeks in all patients. Conclusion: In scrotum defects that occur after Fournier's gangrene, the approximating suture technique performed at appropriate tension after the release of the contractures of scrotal flaps with scoring incision provides good stretching of the scrotal flaps and closure of the wounds at appropriate times. ÖZET Amaç: Fournier gangreni, skrotal, perianal ve genital bölge-lerde aerobik ve anaerobik bakterilerin mikro tromboz oluşturarak doku nekrozuna neden olması sonrası fasiyaya uzanarak gövde ve ekstremi-telere yayılan sinsi bir hastalıktır. Erkek hastalarda, diyabet hastala-rında, bağışıklığı baskılanmış hastalarda ve cerrahi işlem geçirenlerde daha sık görülen bu hastalık aynı zamanda yüksek morbidite ve mor-taliteye sahiptir. Bu çalışmada, kliniğimizde uyguladığımız skrotal flep-lerin skorlama kesisini ve uygun gerginlikte yaklaşım dikiş tekniğini sunmak amaçlanmıştır. Gereç ve Yöntemler: Fournier gangreni son-rası primer cerrahi debridman işlemleri sonlandırılan hastalar defektle-rinin kapatılması için kliniğimize yatırılan hastalar Ocak 2016-Temmuz 2021 tarihleri arasında retrospektif olarak tarandı. Çalışmada; ortalama yaş, defekt boyutu ve lokalizasyonu, eşlik eden hastalıklar, üreyen mik-roorganizmalar, ameliyat süresi, hastanede yatış süresi, yaraların iyi-leşme süresi ve komplikasyonlar gibi veriler incelendi. Bulgular: Hastaların ortalama yaşı 61,1 yıl olup, en sık eşlik eden hastalıklar diabetes mellitus ve solunum yolu hastalığıdır. Beta-hemolitik strepto-koklar en çok üreyen mikroorganizmalardır. Tüm hastalarda 4-7 haftada defektler kapatılmıştır. Sonuç: Fournier gangreni sonrası olu-şan skrotum defektlerinde skrotal fleplerin kontraktürleri skorlama in-sizyonu ile gevşetildikten sonra uygun gerginlikte yapılan yaklaştırma sütür tekniğiyle skrotal fleplerin iyi bir şekilde esnetmekte ve yaraların uygun zamanlarda kapatılmasına olanak sağlamaktadır. Anah tar Ke li me ler: Fournier gangreni; skorlama insizyonu; skrotal flep; yara yaklaştırma ORİJİNAL ARAŞTIRMA ORIGINAL RESEARCH
... We have seen minor complications such as margin necrosis in two patients of medial thigh flap coverage however, both cases were managed conservatively and the flaps showed good sensation except for transient loss of sensation over anterior part of thigh which regained in the follow-up period. These advantages and disadvantages were comparable to that reported by Ferreira et al. [19] in their review of management of 43 patients of Fournier's gangrene. Donor site complications such as wound dehiscence and infection of the donor site suture line were seen in two patients and one patient respectively. ...
... Direct closure was done for wound dehiscence and infection was managed by frequent dressing. These minor complications were comparable to that reported by Ferreira et al. [19]. ...
Background
Scrotal defects in developing countries are common challenges for the reconstructive surgeon and hence this work has been done with the aim to compare the outcome, advantages and disadvantages of different modalities of scrotal reconstruction.
Methods
The prospective observational hospital-based study of reconstruction of scrotal defects following trauma and Fournier’s gangrene was done over a period of three years. Scrotal defect reconstruction was done in 35 patients by scrotal advancement flap, split thickness skin grafting, medial thigh flap, anterolateral thigh flap and groin flap keeping in mind the various indication of different modalities. The reconstructed scrotums were observed for flap survival and skin graft intake for seven to 10 days in the hospital and then were followed for three months in a follow-up clinic.
Results and observations
The mean age of our patients was 48.57±5.01 years. Most of the soft tissue defects of the scrotum were post-traumatic (83%). Scrotal reconstruction was done often by flaps and more frequently used flap for reconstruction of scrotum was scrotal advancement flap. All flaps and grafts survived well. Mean hospitalization time was highest for groin flap cover whereas mean operative time was highest for anterolateral thigh flap cover.
Conclusion
Every case of scrotal defect needs an individual approach for scrotal reconstruction depending upon patient age, general condition of the patient, wound status, and the patient’s requirement.
... Entre los procedimientos que se pueden realizar es movilización de colgajo de espesor completo, colgajo miocutáneo, colgajo cutáneo o afrontar los bordes de la herida. El avance de colgajo en especial es útil cuando se trata de heridas pequeñas en escroto, sin embargo, en el caso de nuestros pacientes presentaban heridas que involucraban ambas bolsas escrotales, periné, en ocasiones, pene o pubis, para lo cual se requiere otro tipo de procedimiento para lograr cubrir por completo la herida.(9,10) Para cubrir áreas amplias se pueden utilizar con seguridad los colgajos de espesor completo, sin embargo, estos tienden a contraerse, y en caso de que existan concavidades puede generar un espacio muerto que no permite el proceso de adaptación del injerto, para lo cual puede usarse un colgajo fasciocutáneo o miocutáneo para rellenarlo. ...
... En nuestro caso utilizamos colgajos de espesor completo al ser heridas complejas, teniendo en ocasiones necrosis de los bordes, sin embargo, evolucionaron de manera adecuada. De cualquier manera, no existe un consenso sobre el procedimiento de elección para cubrir las secuelas ocasionas por la gangrena de Fournier.(10)(11)(12) ...
Descripción del caso clínico:
Dos pacientes hombres, con edad de 47 y 39 años, antecedente en común diabetes mellitus tipo 2 desarrollaron Fournier, realizando debridación de urgencia y manejo con antibióticos de amplio espectro, requiriendo dos o más aseos quirúrgicos, un paciente usó cierre asistido por vacío. Posterior a su recuperación se realizó procedimiento reconstructivo con avances de colgajo y con injerto de piel autóloga de espesor completo extraído del muslo respectivamente.
Relevancia:
El Fournier es una infección con alta mortalidad que involucra tejidos blandos de región perineal y genital en inmunocomprometidos, requiriendo manejo quirúrgico agresivo que deja secuelas anatómicas y funcionales importantes. Cuando el paciente se recupera, existe poca evidencia del seguimiento y manejo de las secuelas del Fournier.
Implicaciones clínicas:
La terapia reconstructiva tiene como finalidad reincorporar al paciente a su vida normal tratando de mantener una anatomía cercana a la normalidad y funcional. Aún no existen directrices sobre el mejor método de reconstrucción para las secuelas de Fournier, sin embargo, usar injertos es la mejor medida observada.
Conclusión:
Usar injertos cutáneos de espesor completo autólogos resulto benéfico para nuestros pacientes, sin embargo, se debe realizar una revisión de la literatura para estandarizar el uso de injertos y las técnicas reconstructivas de acuerdo con las secuelas.
... A gangrena de Fournier é uma doença incomum e potencialmente fatal, originalmente descrita em 1883 pelo venereologista francês Jean Alfred Fournier (1) que consiste em uma fasciíte necrosante polimicrobiana das áreas perineal, perianal ou genital, muito frequentemente relacionada a fatores predisponentes conhecidos como a infecção por HIV, alcoolismo, diabetes mellitus, uso crônico de esteroides, desnutrição e malignidade (2,3). É fatal em 20% a 30% dos casos (2), podendo resultar em deformidade extensa e incapacitante nos pacientes sobreviventes (3)(4)(5)(6)(7)(8)(9). ...
... A gangrena de Fournier é uma doença incomum e potencialmente fatal, originalmente descrita em 1883 pelo venereologista francês Jean Alfred Fournier (1) que consiste em uma fasciíte necrosante polimicrobiana das áreas perineal, perianal ou genital, muito frequentemente relacionada a fatores predisponentes conhecidos como a infecção por HIV, alcoolismo, diabetes mellitus, uso crônico de esteroides, desnutrição e malignidade (2,3). É fatal em 20% a 30% dos casos (2), podendo resultar em deformidade extensa e incapacitante nos pacientes sobreviventes (3)(4)(5)(6)(7)(8)(9). Tais deformidades podem representar sequelas anatômicas, funcionais e psicológicas importantes para os pacientes. ...
A 70-year-old diabetic male presented at the emergency room with the uncommon Fournier’s Gangrene of the scrotum. After initial extensive clinical care and necrosis excision, the large full thickness scrotum defect was successfully reconstructed with local advancement skin flaps. The clinical indications and advantages of this technique for this patient, over the skin grafting frequently found in the literature are discussed.
... Entre los procedimientos que se pueden realizar es movilización de colgajo de espesor completo, colgajo miocutáneo, colgajo cutáneo o afrontar los bordes de la herida. El avance de colgajo en especial es útil cuando se trata de heridas pequeñas en escroto, sin embargo, en el caso de nuestros pacientes presentaban heridas que involucraban ambas bolsas escrotales, periné, en ocasiones, pene o pubis, para lo cual se requiere otro tipo de procedimiento para lograr cubrir por completo la herida.(9,10) Para cubrir áreas amplias se pueden utilizar con seguridad los colgajos de espesor completo, sin embargo, estos tienden a contraerse, y en caso de que existan concavidades puede generar un espacio muerto que no permite el proceso de adaptación del injerto, para lo cual puede usarse un colgajo fasciocutáneo o miocutáneo para rellenarlo. ...
... En nuestro caso utilizamos colgajos de espesor completo al ser heridas complejas, teniendo en ocasiones necrosis de los bordes, sin embargo, evolucionaron de manera adecuada. De cualquier manera, no existe un consenso sobre el procedimiento de elección para cubrir las secuelas ocasionas por la gangrena de Fournier.(10)(11)(12) ...
Descripción del caso clínico: Dos pacientes hombres, con edad de 47 y 39 años, antecedente en común diabetes mellitus tipo 2 desarrollaron Fournier, realizando debridación de urgencia y manejo con antibióticos de amplio espectro, requiriendo dos o más aseos quirúrgicos, un paciente usó cierre asistido por vacío. Posterior a su recuperación se realizó procedimiento reconstructivo con avances de colgajo y con injerto de piel autóloga de espesor completo extraído del muslo respectivamente. Relevancia: El Fournier es una infección con alta mortalidad que involucra tejidos blandos de región perineal y genital en inmunocomprometidos, requiriendo manejo quirúrgico agresivo que deja secuelas anatómicas y funcionales importantes. Cuando el paciente se recupera, existe poca evidencia del seguimiento y manejo de las secuelas del Fournier. Implicaciones clínicas: La terapia reconstructiva tiene como finalidad reincorporar al paciente a su vida normal tratando de mantener una anatomía cercana a la normalidad y funcional. Aún no existen directrices sobre el mejor método de reconstrucción para las secuelas de Fournier, sin embargo, usar injertos es la mejor medida observada. Conclusión: Usar injertos cutáneos de espesor completo autólogos resulto benéfico para nuestros pacientes, sin embargo, se debe realizar una revisión de la literatura para estandarizar el uso de injertos y las técnicas reconstructivas de acuerdo con las secuelas.
... Среднее время от появления симптомов до госпитализации составляет ~5,1 ± 3,1 дней. Отли-чительной чертой гангрены Fournier также считается молниеносное прогрессирование симптомов: от эритемы, отека и боли до образования пузырей, клинически видимой ишемии и, в конечном счете, гнилостных некротических поражений [16]. ...
Introduction. Fournier gangrene is a life-threatening form of perineal necrotizing infection characterised by affecting immucompromised patients, including those with tuberculosis.
Objective. To evaluate the treatment results of patients with Fournier gangrene and tuberculosis process.
Materials & methods. Five case histories of patients diagnosed with "Fournier gangrene" at the Tuberculosis Extrapulmonary Division of Clinic No. 2, Moscow Research Clinical Centre for Tuberculosis Control from 2012 to 2022 were analysed retrospectively using the continuous method. The Fournier's Gangrene Severity Index (FGSI) was used for assessment.
Results. The analysis of case histories revealed the main features of management in patients with Fournier gangrene whose underlying process was tuberculosis. Our clinical experience confirms the role of Mycobacterium tuberculosis as a specific agent, as well as an immunosuppression factor in the development of Fournier’s gangrene. One should be wary of this pathology in patients with tuberculosis. The aggressive nature of the infectious process dictates the need for early detection of this disease for competent comprehensive treatment, including early rehabilitation of chronic foci of infection in patients with urogenital pathology and reconstructive-plastic methods of surgical treatment.
Conclusion. Fournier gangrene in tuberculosis patients is a rare difficult-to-treat disease accompanied in most cases by septic shock and a high mortality risk. Alertness towards Fournier gangrene in patients with tuberculosis, correctly chosen treatment tactics reduces the risk of lethal outcomes.
... Hence, several papers described minor complications such as margin necrosis in a flap reconstruction group. However, direct closure was performed for wound dehiscence and infection was managed by frequent dressing [3,82]. Every flap used to cover scrotal defect has its own pros and cons, so every case needs an individual approach. ...
This review delves into reconstructive methods for scrotal defects arising from conditions like Fournier’s gangrene, cancer, trauma, or hidradenitis suppurativa. The unique anatomy of the scrotum, vital for thermoregulation and spermatogenic function, necessitates reconstruction with thin and pliable tissue. When the scrotal defect area is less than half the scrotal surface area, scrotal advancement flap can be performed. However, for larger defects, some type of transplantation surgery is required. Various options are explored, including testicular transposition, tissue expanders, split-thickness skin grafts, local flaps, and free flaps, each with merits and demerits based on factors like tissue availability, defect size, and patient specifics. Also, physicians should consider how testicular transposition, despite its simplicity, often yields unsatisfactory outcomes and impairs spermatogenesis. This review underscores the individuality of aesthetic standards for scrotal reconstruction, urging surgeons to tailor techniques to patient needs, health, and defect size. Detailed preoperative counseling is crucial to inform patients about outcomes and limitations. Ongoing research focuses on advancing techniques, not only anatomically but also in enhancing post-reconstruction quality of life, emphasizing the commitment to continuous improvement in scrotal reconstruction.
... IVIG has been shown to be beneficial in patients with GAS NF that progressed into toxic shock syndrome. 74,[111][112][113] Researchers have linked the efficacy of IVIG in NF to its ability to reduce a systemic inflammatory response by targeting the exotoxins. 114 IVIG has also shown some benefits in high-risk patients, including those with advanced age, bacteremia, and hypotension. ...
Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.
... Ряд состояний и сопутствующих заболеваний предрасполагают к развитию ГФ -это сахарный диабет, гипертония, алкоголизм, пожилой возраст, недоедание, ожирение, хроническая почечная недостаточность, хронические заболевания печени, злокачественные новообразования [3,[14][15][16][17]. Сахарный диабет встречается у 56,0 % пациентов с ГФ [18,19]. ...
The authors describe a clinical case of successful treatment of a patient with an ischiorectal abscess complicated by extensive purulentnecrotic phlegmon on the anterior abdominal wall and right thigh. Topical negative pressure wound technique (NPWT) was used. Its combination with surgical debridement and rational systemic antibiotic therapy has been shown to contribute to successful treatment of this life-threatening pathology.
... Kızılay et al 26 reported that hospitalization period of FG patients treated with vacuum assisted closure was 23.6 days on average and was significantly shorter than patients treated with conventional dressings. In his review study, Ferretti et al 27 emphasized that average length of stay in the hospital was 32 days, whereas it was 73.6 ± 42.5 days according to Ferreira et al. 23 In our study, mean hospitalization duration was determined as 23.5 ± 5.0 days in group 1 and 31 ± 8.3 days in group 2. In the literature, the significant effect of the surgical technique on the hospitalization period in patients with FG is unknown. However, in FG, one of the most important criteria for the success of a surgical technique is a shorter duration of hospitalization after definitive reconstruction. ...
Purpose:
The treatment of Fournier's gangrene (FG) includes aggressive debridement of the affected necrotic area, broad-spectrum antibiotic therapy, and reconstructive procedures, respectively. One of the main reasons of unfavorable outcomes in FG surgery is that the dead space occurs in the perianal region because of destruction of fascias and soft tissues. In this study, we aimed to evaluate the results of gracilis muscle flap transposition to fill the FG-associated perianal dead spaces.
Methods:
Patients treated for FG-associated dead spaces in their perianal region between the years 2017 and 2021 were included in the study. The patients who underwent the pedicled gracilis muscle flap surgery were included in group 1, whereas group 2 consisted of the patients with no additional surgical procedure for dead spaces but only the reconstruction of the soft tissue defects. Demographic data (age, sex), comorbid diseases, localization and length of perianal dead space, and management method for the soft tissue defects and complications were noted. The length of hospital stay and discharge day after surgery were also recorded.
Results:
In group 1, the mean duration of hospital stay was 23.5 ± 5.0 (range, 14-48) days, whereas the mean period between the surgery and discharge was 5.1 ± 2.2 (range, 3-12) days. These numbers were 31 ± 8.3 (range, 19-58) days and 12.7 ± 6.1 (range, 7-22) days in group 2, respectively. Statistical comparison of the periods between the surgery and discharge was found to be significantly different (P = 0.022). The duration of hospital stay was also shorter in the patients with gracilis muscle flap (P = 0.039).
Conclusions:
Perianal dead spaces accompanying many of the patients with FG provide appropriate conditions for bacterial colonization. Filling these pouches by the gracilis muscle flap prevented the progression of infection and enabled the patients to return to their normal life earlier.
... Расходы на лечение одного пациента в среднем составляют 27 646 долларов (для выживших больных -26 574 долларов, для умерших -40 871 долларов) [113]. После выписки из стационара не менее 30% пациентов нуждается в постоянном уходе и более 50% -в повторных реконструктивно-пластические операциях на наружных гениталиях и промежности [1,5,38,48,49,55,64]. ...
В представленном обзоре литературы освещаются современные аспекты эпидемиологии, этиологии, патогенеза, клинико-лабораторной картины, лучевой диагностики и лечения редких гнойно-некротических заболеваний мужских наружных половых органов, к которым относятся карбункул мошонки, гидраденит лона, кавернозный и бульбарный абсцессы полового члена, подкожный абсцесс срединного шва полового члена, абсцесс мошонки и молниеносная гангрена мошонки (гангрена Фурнье). Эти заболевания обычно наблюдаются у мужчин социально активного и репродуктивного возраста с иммунодефицитным коморбидным фоном. Обсуждаются новые методы адьювантного лечения пациентов с гангреной Фурнье, такие как гипербарическая оксигенотерапия и вакуум-терапия. Обращается внимание, что прогноз гнойно-некротических заболеваний наружных половых органов зависит, прежде всего, от своевременной диагностики и сроков хирургического вмешательства.Ключевые слова: гнойно-некротические заболевания мужских наружных половых органов, этиопатогенез, диагностика, лечение
... It can be considered when the underlying infection is systemically eradicated, and the patient is making a good recovery which in practice means at least 5-7 days after the last debridement (Hagedorn and Wessells 2017). Reconstructive procedures involve coverage of the skin and soft tissue using split thickness skin grafts, full thickness skin grafts, local advancement flaps, fasciocutaneous flaps, myocutaneous flaps, or muscle flaps ( Fig. 1) (Ferreira et al. 2007;Chen et al. 2010a, b). Transplantation of the testes may be required in some cases. ...
... La reconstrucción escrotal es un procedimiento que se realiza a pacientes con áreas cruentas de la región genital, perineal o perianal. La causa de la formación de estas áreas cruentas en su mayoría de casos de debe al síndrome de Fournier una enfermedad de etiología desconocida, aunque tiene sus grupos de riesgo como los pacientes diabéticos, inmunosupresos, con patología colorectal o alcoholismo.[1,2,3] Luego de instaurar un adecuado tratamiento del síndrome de Fournier, el cual incluye llevar a sala de operaciones inmediatamente a realizar desbridamiento exhaustivo del área infectada, la antibioticoterapia dirigida y curaciones debridantes posteriores. ...
La reconstrucción escrotal es un procedimiento que se realiza a pacientes con áreas cruentas de la región genital, perineal o perianal. La causa de la formación de estas áreas, en su mayoría de casos, de debe al síndrome de Fournier, una enfermedad de etiología desconocida, aunque tiene sus grupos de riesgo como los pacientes diabéticos, inmunosupresos, con patología colorectal o alcoholismo. La gangrena de Fournier es una emergencia urológica cuyo objetivo final es la reconstrucción escrotal, la cual se llevó a cabo en el presente caso.
... When the Fournier's disease interests the penis rod, other reconstruction strategies are advisable. Thick skin grafts are recommended for their minimal contraction compared to thin skin grafts [32]. Penile skin grafting does not appear to interfere with sexual and erectile function in these cases [33]. ...
Background
Fournier’s gangrene is a rare form of necrotizing fasciitis that affects the genital area up to the perineal region and sometimes the abdominal wall.
Objectives
Our article aims to show that in the treatment of extensive forms of Fournier’s gangrene, correct use of flap and skin grafts and a quick reconstruction of the exposed tissues avoid scarring retraction of the testicles and deformation of the penis.
Materials and methods
We retrospectively reviewed the clinical and photographic data of Fournier’s gangrene cases treated at our Institute. The data were evaluated to obtain an estimate of the results of the reconstructive technique used, in terms of percentage of occurred healings and eventual complications.
Results
A total of 34 patients underwent surgery for Fournier’s gangrene. In nine cases (26.5%), we had minor complications: in four patients, suffering from diabetes and obesity, a retard in attachment of graft occurred, while in five patients with perianal problems there was a delay in healing due to the onset of local infection.
Conclusion
The reconstruction approach described here may reduce surgical times. In Fournier’s gangrene, the exposed tissues must be reconstructed as quickly as possible.
... It was previously considered to have an idiopathic aetiology, but now is considered to be a consequence of infective origin associated with urologic and colorectal disorders. The management involves radical and aggressive debridement which results in a challenging penoscrotal defect [8]. The major skin and soft tissue loss often becomes a concern for reconstructive specialist, and many techniques have been described for reconstruction [9,10]. ...
Background
Large penoscrotal defects with exposed testis are a challenge to reconstruct. Muscle flaps provide an excellent option to reconstruct such defects. The aim of the article is to present the authors’ experience in using gracilis muscle flap in the reconstruction of penoscrotal defects following Fournier’s gangrene.Methods
All patients with Fournier’s gangrene who underwent a soft tissue reconstruction using unilateral gracilis muscle flap from January 2013 to November 2018 were prospectively included in the study. Patients with exposed testis, penoscrotal defects and dead spaces to fill were included, and exclusion criteria were persistent infection, large defects requiring bilateral gracilis or expected shortfall of coverage using unilateral gracilis muscle. Postop aesthetic assessment was done using modified Vancouver Scar Scale (mVSS) after 6 months by an independent reviewer.ResultsFourteen cases of post Fournier’s gangrene defects were reconstructed by using gracilis muscle flap with split skin graft in a tertiary care hospital. All were male patients. Age ranged from 20 to 72 years with mean age 35.5 years. After debridement and regular dressings, operation was done under general or spinal anaesthesia. All flaps survived well and there were no major complications encountered. All the patients had acceptable aesthetic outcomes on mean follow-up of 13.2 months.Conclusions
The pedicled gracilis muscle flap with split skin graft is a good option for large defects involving penis, scrotum and perineum, especially in Fournier gangrene. This flap offers minimal donor site morbidity and minimal major complications with acceptable cosmetic outcomes.Level of evidence: Level IV, therapeutic study.
... A pesar del manejo avanzado, la mortalidad sigue siendo elevada, 3%-67%, dependiendo de las series 8 . Después del desbridamiento quirúrgico inicial, se requiere habitualmente de varios aseos quirúrgicos 9,10 que originan en muchos pacientes significativos defectos de piel y partes blandas necesitando de la cirugía reconstructiva para lograr una adecuada cobertura, resultados funcionales y cosméticos satisfactorios 11 . Dentro de las técnicas de reconstrucción utilizadas para estos fines se encuentran: cierre primario, cierre por segunda intención, injertos de piel parcial (IPP), colgajos y la combinación de las anteriores. ...
Objetivo:
Describir el manejo quirúrgico realizado para la reconstrucción genitoperineal (RGP) en pacientes con secuelas de Gangrena de Fournier (GF).
Materiales y Método:
Corresponde a una serie de casos retrospectiva de pacientes con secuelas de GF a los que se les realizó RGP entre los años 2011 y 2019. Se realizó un análisis descriptivo con las variables de técnica quirúrgica, edad, sexo, comorbilidades, subunidades anatómicas afectadas, origen anatómico de la gangrena de Fournier, número de procedimientos quirúrgicos, procedimiento de colostomía, terapia de presión negativa, Flexi-Seal®, bacterias aisladas, duración de estancia hospitalaria, tipo de procedimientos reconstructivos y complicaciones.
Resultados:
Se realizó RGP a 43 pacientes (81,1% hombres), con un promedio de edad de 59,1 (17-86 años), 72,7% eran diabéticos. El número de subunidades involucradas se asocia directamente y significativamente en relación al número de intervenciones quirúrgicas. Las técnicas utilizadas para la reconstrucción en orden de frecuencia fueron: colgajos (23%), cierre parcial más injerto dermoepidérmico de grosor parcial (IPP) (20%), cierre parcial (16%) e IPP (16%), cierre por segunda intención (10%), colgajo más IPP (7%) y cierre parcial para cierre por segunda intención de zona restante (5%).
Discusión:
La elección de reconstrucción se basa en las características del defecto, es decir, el tamaño, la ubicación y profundidad, así como la disponibilidad de tejido local. De preferencia optar por cierres primarios sin tensión, seguido de colgajos y de IPP.
Conclusión:
La RGP es un desafío para el cirujano plástico. Las técnicas descritas han demostrado ser seguras y reproducibles para el tratamiento quirúrgico de la gangrena de Fournier.
... ~ 214 ~ As the subcutaneous inflammation worsens, necrosis and suppuration of subcutaneous tissues progresses to extensive necrosis. Patients can rapidly deteriorate as sepsis and multiorgan failure, the most common cause of death in these cases, develop [11][12][13][14] . Fournier gangrene is a true urological emergency. ...
Background:
Scrotal reconstruction is needed in response to multiple conditions, such as Fournier’s Gangrene. In this scenario, thorough debridement is necessary in order to achieve definite healing, the next step being scrotal reconstruction, for which a search for optimal aesthetic and functional outcomes should be the norm. In the authors’ experience, the bilateral pedicled gracilis flap allows for the meeting of these standards.
Objective:
To revise the published literature on scrotal reconstruction using pedicled gracilis flaps after Fournier’s Gangrene, collecting data on defect size, reconstructive method and complication rates, followed by a detailed description of the technique, in which the authors share some technical notes and present a one-year follow-up case.
Design, setting and participants:
We conducted a systematic review on the published literature following PRISMA2020 recommendations, which yielded 9 studies. We analyse them for collection of previously defined variables and share the case of one patient, in order to compare our experience with the published literature.
Results:
Nine studies including 30 patients were analysed in our review. The mean age was 45.99 and mean defect size 12.25 cm x 11.5 cm. For 16 of these patients, a musculo-cutaneous flap was used, whereas in the other 14 muscle flaps were elevated and then grafted. There were no reports of flap failure or major complications in any of the studies.
Conclusions:
The pedicled gracilis flap is an excellent option for scrotal reconstruction following Fournier’s Gangrene. It provides optimal coverage and allows for a functional and aesthetic reconstruction.
Objective
To examine the role of bowel diversion and reconstructive surgeries in managing Fournier's gangrene (FG) to facilitate multidisciplinary collaboration between urologists, colorectal and plastic surgery teams.
Methods
A review of the literature was conducted using the databases Medline, Embase, PubMed in June 2023. The review included studies that evaluated the outcomes of FG following reconstructive surgeries or diverting colostomies.
Results
The existing evidence suggests that bowel diversion and colostomy formation could reduce the need for further debridement, shorten the time to wound healing, and facilitate skin graft or flap uptake in patients with FG. Additionally, the psychological impact of a stoma was shown not to be a major concern for patients. However, stoma carries a risk of perioperative complications and therefore may prolong the length of hospital stay. In reviewing the evidence for reconstruction in FG, large and deep defects seem to benefit from skin grafts or flaps. Noticeably, burial of testicles in thigh pockets has grown out of favour due to concerns regarding the thermoregulation of the testicles and the psychological impact on patients.
Conclusion
The use of bowel diversion and reconstructive surgeries in managing FG is case dependent. Therefore, it is important to have close discussions with colorectal and plastic surgery teams when managing FG.
Male genital dermatoses present a diverse array of symptoms including itch, pain, cracking, blistering, bruising, dysuria and dyspareunia, and can affect quality of life in terms of sexual, dermatological, psychological and urological morbidity. Dermatoses such as psoriasis, lichen planus and atopic eczema may manifest in specific morphology in the genital region, while other dermatoses such as lichen sclerosus, have a genital predilection, and subtle clinical signs that require assiduous assessment and a trained eye to detect. Treatment may present similar challenges due to the essential functions and associated stressors in the region. Precancerous pathologies also present challenges in terms of clinical recognition, and treatment, with diverse morphologies and region‐specific predisposing factors, and surgical challenges in terms of preserving sexual and urinary function.
Meme kanseri, dünya çapında kadınlarda en sık görülen kanser türüdür ve kanserden ölümlerin en sık nedenidir. Fizik muayenede meme kanserinden şüphe duyulduğunda tanısal görüntüleme yöntemlerine başvurulmaktadır. Böyle bir durumda mamografi, ultrasonografi (USG) ve manyetik rezonans görüntüleme (MRG) en sık kullanılan görüntüleme yöntemleridir. Genel olarak, meme kanseri tanısında önerilen görüntüleme seçenekleri arasında tanısal mamografi ve meme USG yer alır; bunların seçimi hastanın yaşına ve klinik/radyolojik şüphenin derecesine bağlıdır. Uygun endikasyon ve gereklilik durumunda meme MRG yol gösterici ve sorun çözücü olabilir.
Fournier's gangrene is a progressive necrotizing bacterial dermo-hypodermitis of the perineum and external genitalia. It represents a secondary polymicrobial infection with an aerobic and anaerobic group of bacteria, which have a synergistic effect in the development of this disease. Fournier's gangrene is an urgent, potentially life-threatening, medical condition that requires a multimodal approach: surgical debridement of the necrotic tissue, resuscitation of the patient, and the application of a broad spectrum of antibiotic therapy. We present the case of a 45-year-old male, referred to our department due to pain and swelling of the perineal region and scrotum, in the initial stage of Fournier's gangrene. The patient was hospitalized, a surgical incision and drainage of the areas affected by gangrene were made, and he underwent surgical treatment of the wound and intensive suppurative therapy for 23 days. After 23 days of hospitalization, the patient was discharged for home treatment with prior suturing of the incisional wounds, with an orderly local status and good general condition. Timely incision, debridement and application of intensive therapy in a condition such as Fournier's gangrene is of crucial importance. In this way, the possibility of potential complications, the progression of local to systemic disease, as well as the percentage of fatal outcome, is reduced.
Fournier gangrene (FG) is a rare but rapidly progressing disease with a higher mortality rate in women as compared to men. This study aims to perform a literature review about FG in females and associated mortality and morbidity. We searched databases including MEDLINE (Ovid), the National Library of Medicine (Medical Subject Headings (MeSH)), the Cochrane Database of Systematic Reviews (Wiley), as well as Embase (Ovid), Scopus, and Global Index Medicus (WHO), and reviewed literature from 2002 to 2022 and selected 22 studies that met our study's inclusion criteria, which included 134 female patients with a mean age of 55±6 years. The perineal abscess was a more common nidus (n=41, 35%; 95%CI 23-39%) than vulvar pathology (n=29, 22%; 95%CI 15-30%). The most common initial presentation was cellulitis (n=62, 46%; 95%CI 38-55%), followed by perineal pain (n=54, 40%; 95%CI 32-50%), fever (n=47, 35%; 95%CI 27-43%), and septic shock (n=38, 28%; 95%CI 21-37%). Escherichia coli was the most frequently identified bacteria (n=48, 36%; 95%CI 28-46%). All patients had treatment with a mean of three (SD 2) debridement and those with negative pressure dressings received fewer debridements than those who received a conventional dressing. However, of those who had surgical intervention, 28 (20%; 95%CI 14-29%) patients underwent diversion colostomy. General surgeons performed 78% (n=104) of cases out of which 20% (n=20) were consulted by obstetrician-gynecologists, 14% (n=18) were treated by urologists, and only 8% (n=10) by plastic surgeons. The mean length of stay in the hospital was 24±11 days, and the gross mortality rate was 27 (20%; 95%CI 14-28%). In conclusion, while females have a low incidence rate of FG, they carry a higher mortality rate. Lack of cardinal signs and delayed presentation to the hospital from the onset of symptoms are some possible causes for the increased mortality rate along with the disease process being under-recognized in women. A high index of clinical suspicion is essential to avoid delay in the definitive management coupled with an early surgical consult and establishing a common general care pathway could minimize mortality and morbidity.
Background:
Due to its unique cosmetic appearance and functioning, scrotal skin offers a major clinical challenge in terms of reconstruction. Thus, successful reconstruction of scrotal skin should include both provision of pliable texture and protection of testicular functions. Skin grafts and flaps are important options for such reconstruction; however, they both have unique features that bring about specific limitations and specific problems.
Aims and objectives:
In the light of the negativities related to the widely used skin grafts and flaps, this study aims to discuss the use of bilobed pudendal flap-a simple, uniform, and pliable tissue-for the first time in the related literature for the reconstruction of scrotal skin defects caused by Fournier's gangrene.
Materials and methods:
This study was performed using the single-step method of scrotal skin reconstruction on eight patients who had developed scrotal skin defects and underwent reconstruction by using three-dimensional bilobed pudendal flaps (defect and reconstructive tissues planned on different planes) from December 2016 to August 2019.
Results:
No complication such as infection, bleeding, hematoma, partial or complete flap loss, scar contraction, urinary problem, erectile dysfunction or discomfort, or sensation loss was observed in seven out of eight study patients. The only complication to have developed in one patient was minimal dehiscence, which was then corrected by restoration.
Conclusion:
Repair of scrotal skin defect using a three-dimensional bilobed pudendal flap enabled an elastic scrotal repair acceptable in sensorial and visual terms.
A síndrome de Fournier é uma doença infecciosa multi-bacteriana de início insidioso e rápida progressão em região perineal. Seu tratamento inclui desbridamento e antibioticoterapia de amplo espectro, porém, o desbridamento resulta em perda da cobertura cutânea da região perineal. Existem várias técnicas possíveis de reconstrução da área cruenta, como enxertos cutâneos, retalhos miofasciocutâneos e fasciocutâneos, além do fechamento primário da lesão. Sendo assim, este estudo analisou seis pacientes submetidos à cobertura das áreas cruentas com procedimentos reconstrutivos, que variaram desde a aproximação das bordas com sutura simples até uso de retalhos e enxertos, nas lesões com maiores dimensões. As técnicas de reparação cutânea apresentaram boa evolução com resolução da área cruenta, obtendo-se resultados satisfatórios.
Objective
To evaluate the efficacy of early necrotizing soft-tissue infections of the genitalia (NSTIG) component separation, primary wound closure (CSC). We hypothesized that early CSC would be safe, decrease the need for split-thickness skin grafting (STSG) and decrease wound convalescence time.
Materials/Methods
Management of consecutive NSTIG patients from a single institution were evaluated. Three cohorts emerged: 1) those managed/closed by a reconstructive urologist (URO) using CSC principles (wide genital tissue mobilization with primary closure, when possible, +/- STSG), 2) those managed/closed by the general surgery/burn service (GSB), and 3) those managed conservatively with secondary closure. Total NSTIG anatomic extent (AE) was determined by assessing involvement of the penis, scrotum, perineum and suprapubic region, and ranged from 1 (<50% involvement of one area) to 8 (>50% involvement in all 4 areas).
Results
Of 84 FG patients meeting study criteria, 48 (57%) were closed primarily and 36 were left to heal by secondary intention. AE was greatest in patients managed by GSB (4.5 ± 1.5), followed by URO (2.7 ± 1.8) and secondary intention cases (1.3 ± 0.5). Secondary procedure rates were similar between closure/non-closure cohorts (6.3% v 11 %; p = 0.67). STSG use was predicted by wound size (though not time to closure) – specifically with suprapubic and/or penile wounds of >50% involvement. Wound convalescence time decreased by 64% when wounds were closed versus left open, controlling for AE.
Conclusion
Early, same-admission primary closure of stable NSTIG wounds is safe and decreases wound convalescence time by over 60%.
Introduction: We report the experience of the National Center of Burns and Plastic Surgery of Ibn Rochd University Hospital of Casablanca in the coverage of defects secondary to Fournier’s gangrene. Materials and Methods: We retrospectively collected and analyzed clinical, therapeutic, and scalable data of patients referred for perineal coverage after Fournier's gangrene, during a period of 3 years (from January 2018 to December 2020), including age, gender, medical background, Charlson comorbidities index; cause, period of coverage, Performance Status score, the extent of the defect and affected sites, Anesthesia, Surgical technique, and post-operative suites. Results: 46 patients were identified: 43 males (93%) and 3 females (7%); mean age was 53 years. Diabetes was the most common comorbidity (58%). The major cause was proctologic (60.9%). The average consultation time was 44.15 days. The patients presented with defects measuring between 4 cm2 and 800 cm2, mostly affecting the scrotum (80%). Several surgical techniques have been employed and added together, depending on the extent and topography of the defect. 20 were treated by suturing due to sufficient skin laxity, 13 were covered by skin grafting of the penis and/or for an extensive and/or oozing defect. 20 were covered by a scrotal advancement flap for a defect not exceeding half of the scrotum. The fascio-cutaneous flaps, namely the VY advancement flap was performed in 14 patients (uni or bilateral), and the medial thigh flap which was performed in 3 patients, for defects involving the perineum and/or more than half of the scrotum. Seven patients (15.21%) presented coverage technique complications. Conclusion: Adequate coverage of the perineum and external genitalia after the Fournier's gangrene prevents functional sequelae and reduces aesthetic sequelae.
Scrotal defects requiring reconstruction may occur after trauma, cancer, or infection. To maintain good testicular function, the ideal scrotal temperature should be slightly lower than the abdominal temperature. However, large local flaps that are enough to cover the testes cannot be used in all patients. A 74-year-old man presented with scrotal and perineal tissue defects after undergoing debridement for Fournier's gangrene due to rectal carcinoma-induced perforation. The scrotal skin defect was reconstructed using a 22 × 10-cm-free ulnar forearm flap. The postoperative course was uneventful, and at the 14-month follow-up examination, the scrotal skin was found to be thin and pliable. Moreover, the donor site on the left forearm was in an acceptable state and no hand dysfunction due to contracture was observed. Based on our observations, we recommend that the free ulnar forearm flap might be an effective option for scrotal reconstruction, causing little donor site morbidity.
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For the last 32years we have been using island groin flap successfully to cover the scrotal defects in a single stage with good results.This flap utility for single stage urethral fistula repair was first reported bythe senior author in 1987 and was published in Br J Urol.[1] We have performed single stage repair of scrotal defects of medium and moderate size with this flap in 25 cases of Fournier's gangrene and in 4 cases of scrotal avulsion injuries due to road traffic accidents. All had good aesthetic results. More than 50 % scrotal size defects were treated by single groin flap alone. In cases with total loss of scrotum, the groin flap was used along with two superior medial pedicle thigh flaps. Here we have included cases of single stage reconstruction of scrotal reconstruction by island groin flap only. All our patients were operated under spinal anaesthesia. The results were satisfying to the patients. We conclude from our thirty years of experience of utilizing this vascular island groin flap for a single stage repair of scrotal defects of moderate size to be a procedure of better choice.
Fournier gangrene is a progressive necrotizing infection of the external genitalia or perineum that constitutes a urologic emergency. Incidence of Fournier gangrene is rising because of population aging, increasing comorbidities, and widespread use of immunosuppressive therapy, including immunosuppressive regimens used in kidney transplants. This is a rapidly progressive and potentially lethal disease without treatment, and early recognition of the disease, proper management of the predisposing factors, and aggressive surgical debridement are the most essential interventions. We report a rare case of Fournier gangrene in the early postoperative period of a kidney transplant due to a perinephric abscess.
Background
Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes required. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.
Methods
A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI’s (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program ‘Covidence’ facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.
Results
After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier’s gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.
Conclusion
Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.
To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra.
Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage.
After a follow-up of 8 to 40 months, one recurrence developed and required dilation.
The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.
Men with spinal cord injury (SCI) appear to have a greater incidence of bacterial colonisation of genital skin as compared to neurologically normal controls. We report a male patient with paraplegia who developed rapidly progressive infection of scrotal skin, which resulted in localised necrosis of scrotum (Fournier's gangrene).
This male patient developed paraplegia at T-8 level 21 years ago at the age of fifteen years. He has been managing his bladder by wearing a penile sheath. He noticed redness and swelling on the right side of the scrotum, which rapidly progressed to become a black patch. A wound swab yielded growth of methicillin-resistant Staphylococcus aureus (MRSA). Necrotic tissue was excised. Culture of excised tissue grew MRSA. A follow-up wound swab yielded growth of MRSA and mixed anaerobes. The wound was treated with regular application of povidone-iodine spray. He made good progress, with the wound healing gradually.
It is likely that the presence of a condom catheter, increased skin moisture in the scrotum due to urine leakage, compromised personal hygiene, a neurogenic bowel and subtle dysfunction of the immune system contributed to colonisation, and then rapidly progressive infection in this patient. We believe that spinal cord injury patients and their carers should be made aware of possible increased susceptibility of SCI patients to opportunistic infections of the skin. Increased awareness will facilitate prompt recourse to medical advice, when early signs of infection are present.
The use of flaps or grafts is mandatory in patients with longer and complex strictures. In 1995-96 we described a new dorsal onlay graft urethroplasty. Over time, our original technique was better defined and changed. Now this procedure (also named Barbagli technique) has been greeted with a fair amount of enthusiasm in Europe and in the United States.
The patient is placed in normal lithotomy position, and a midline perineo-scrotal incision is made. The bulbar urethra is then free from the bulbo-cavernous muscles, and is dissected from the corpora cavernosa. The urethra is completely mobilized from the corpora cavernosa, it is rotated 180 degrees, and is incised along its dorsal surface. The graft (preputial skin or buccal mucosa) or the flap is fixed and quilted to the tunica albuginea of the corporal bodies. The right mucosal margin of the opened urethra is sutured to the right side of the patch-graft. The urethra is rotated back into its original position. The left urethral margin is sutured to the left side of the patch graft and to the corporal bodies, and the grafted area is entirely covered by the urethral plate. The bulbo-cavernous muscles are approximated over the grafted area. A 16F silicone Foley catheter is left in place.
Dorsal onlay graft urethroplasty is a versatile procedure that may be combined with various substitute materials like preputial skin, buccal mucosa grafts or pedicled flaps.
Objective
To examine the outcome of 23 consecutive patients with Fournier’s gangrene. Patients and methodsPatients’ charts were reviewed retrospectively from all those treated for Fournier’s gangrene between July 1994 and July 1997 at the UCLA affiliated hospitals. ResultsTwenty‐three patients were identified (mean age 51.7 years, range 13–71). The aetiologies included perirectal abscess (43%), urethral stricture (30%), scrotal abscess (21%) and unknown (4%). Predisposing factors included diabetes mellitus (43%), steroids or chemotherapy (21%), alcohol abuse (43%), malignancy (26%) and radiation therapy (9%). All 23 patients initially received wide debridement and placement of a percutaneous suprapubic tube. At the time of the first surgery, total scrotectomy was required in all, colostomy in 17% and penectomy in 4%. An additional 35% required eventual colostomy and an additional 9% required a penectomy. Patients underwent repeat debridement a mean of 2.5 times; the overall survival was 96%. Conclusion
Survival can be improved in patients with Fournier’s gangrene by combining aggressive surgical and medical management. The keys to successful outcome included a high index of suspicion, prompt fluid resuscitation, rapid initiation of broad‐spectrum antibiotics, a multidisciplinary approach, early surgical intervention with radical debridement, haemodynamic support in an intensive care setting, and frequent repeat operative debridement.
Perineoscrotal gangrene (Fournier's disease, a specific type of necrotizing fasciitis) is a rare and potentially fatal clinical entity characterized by progressive spread of necrosis in the skin and subcutaneous tissues combined with severe systemic sepsis. We analyzed retrospectively seven patients with perineoscrotal gangrene, illustrating the various clinical presentations, problems in management, and specific approaches to therapy. On admission all patients were evaluated as being in critical condition, having severe systemic disease and rapidly advancing gangrene. After hemodynamic stability was achieved broad spectrum antibiotics were started, and aggressive surgical treatment initiated. In all the patients the infection originated from the anorectal area and proved to be polymicrobial in nature. Six patients survived and were able to be discharged from hospital there was one death on the fifth postoperative day due to pulmonary embolism. The crucial points in the management of this infection remains early diagnosis, wide and repeated surgical débridements, and appropriate antibiotic therapy.
Six dartos musculocutaneous flaps have been used to resurface proximal penile defects. The vascular anatomy of the flap, surgical technique and complications are described in detail.
Scrotal reconstruction with adequate protection of the testicles remains the challenge following Fournier's gangrene. Early single-staged sensate flap coverage is ideal. This is readily accomplished using the medial thigh fasciocutaneous flap based on the longitudinal axiallty of the anteromedial thigh suprafascial plexus. Only a single lower extremity need be violated, and the ipsilateral gracilis muscle may be simultaneously independently elevated for closure of larger defects. Primary donor site closure obviates the need for skin grafts.
A one-stage procedure is described for restoring the scrotum in a patient who suffered from Fournier's gangrene. The proximal superiomedial-based thigh flaps employed are most likely arterial flaps. These flaps are also well innervated, which makes them ideal for the purpose of scrotal reconstruction.
We have done four cases of scrotal reconstruction. In these patients, the scrotal skin was lost as a result of either gangrene of the scrotum or from trauma, surgical or mechanical. The technique of coverage by thigh flaps is a single-staged operation. It gives a pleasing appearance to the genitalia and maintains the testicular function.
We present this case utilizing bilateral gracilis myocutaneous flaps as an acceptable alternative in the approach to scrotal reconstruction in a contaminated field.
Traditionally, reconstruction of the scrotum has involved the use of split skin or pedicle flaps with often unsatisfactory aesthetic results. We present two cases with loss of the scrotum as a consequence of Fournier's gangrene. The use of tissue expanders for scrotal reconstruction involves the following advantages: excellent functional and cosmetic results, natural appearance of the neoscrotum, preservation of normal function and sensitivity of scrotal skin, no additional scars from skin grafting, and a simple surgical technique.
Fournier's gangrene (FG) is an extensive fulminant infection of the genitals, perineum, or the abdominal wall. We report our experience with the management of this difficult infectious disease.
Thirty-eight patients were admitted with the diagnosis of FG between May 1993 and May 1995. All patients were treated with broad-spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and application of unprocessed honey dressings. Patients then underwent split-thickness skin grafts or delayed closure as needed.
Patient ages ranged between 33 and 86 years (mean, 54) with a mean hospital stay of 17 days (range, 1 to 45). Sixty-six percent of the patients were diabetic, 16% had previous orchiepididymitis, and 5% had scrotal and urethral trauma. All the patients underwent surgical debridement and application of unprocessed honey to the wound. Cystostomy was performed in 60% of the patients and 21% underwent orchiectomy of the affected side. Free skin grafts were applied to 6 patients (16%) and the remaining wounds, once clean, were approximated. One patient died as a result of severe metabolic acidosis and sepsis.
The management of this infectious entity should be aggressive. Patients with FG need extensive debridement and cystostomy or colostomy when necessary. Broad-spectrum triple antimicrobial regimen and aggressive debridement are mandatory. Topical application of unprocessed honey is beneficial to the healing process. A minority of patients require split-thickness skin grafts on denuded areas.
Fournier's gangrene, an anaerobic necrotizing cellulitis of the infradiaphragmatic soft tissues, is a serious pathologic entity with an unpredictable course. From 1978 to 1991, a total of 24 men (mean age, 57 years; range 27 to 90) were treated for this entity at our institution. Diagnosis prompted immediate institution of multimodal treatment combining triple antibiotics, surgical dissection, debridement, and repeated surgical drainage. Fecal diversion (16 patients), hyperbaric oxygenation, and standard intensive care procedures were widely indicated and performed quasi-systematically. The mean interval between initial symptoms and diagnosis was 7.4 days. Lesions were limited to the perineum in 11 patients but extended to the abdomen, thighs, or loins in the remaining 13. The pathogens were identified in 19 patients, and hemoculture results were positive in 5. A coloproctologic origin was identified in 12 patients and a urogenital origin in 4. In 2 patients, perineal gangrene occurred postoperatively, and no etiology was determined for 6. Six patients died, and 18 patients recovered, without any sequelae. The prognosis is better when the patient is young (less than 60 years old), has clinically localized disease, without systemic involvement, and sterile hemocultures and is managed with colostomy. A thorough workup is mandatory to determine the etiology (locoregional lesion, malignancy, hemopathy, arteritis).
In 2 seriously ill patients with scrotal swelling of uncertain origin, scrotal and perineal ultrasonography demonstrated gas in the soft tissue before crepitus was detected on physical examination. Necrotizing infections of the scrotum and perineum have characteristic ultrasonographic features that can facilitate earlier diagnosis and treatment.
Many controversial issues exist surrounding the disease pathogenesis and optimal management of Fournier's gangrene. In Fournier's original descriptions, the disease arose in healthy subjects without an obvious cause. Most contemporary studies, however, are able to identify definite urologic or colorectal etiologies in a majority of cases. To investigate disease presentation, treatment modalities, and overall mortality, a retrospective analysis of Fournier's gangrene from a single institution is presented. Since 1990, 26 cases of Fournier's gangrene have been diagnosed at the University of Tennessee. An evaluation of intercurrent disease revealed that 38 percent of the patients had diabetes mellitus, 35 percent manifested ethanol abuse, and 12 percent were systemically immunosuppressed. Fifteen patients (58 percent) presented with identifiable etiologies for their disease: 31 percent (8) urethral disease or trauma, 19 percent (5) colorectal disease, and 8 percent (2) penile prostheses. Management in all cases involved prompt surgical debridement with initiation of broad-spectrum antibiotics. Multiple debridements, orchiectomy, urinary diversion, and fecal diversion were performed as clinically indicated. Fourteen patients received hyperbaric oxygen as adjuvant therapy. Statistically significant results were noted with mortality rates of 7 percent in the group receiving hyperbaric oxygen (n = 14) versus 42 percent in the group not receiving hyperbaric oxygen (n = 12). Overall mortality was 23 percent. Controversy still surrounds disease pathogenesis in Fournier's gangrene, particularly in regard to etiology. Our study corroborates current trends in that a clear focus or origin was identified in a majority of the cases. Although a grim prognosis usually accompanies the diagnosis, this study shows significant improvement combining traditional surgical and antibiotic regimens with hyperbaric oxygen therapy.
We report a case of a large perforated adenocarcinoma of the rectum manifesting as an ischiorectal abscess progressing to Fournier's gangrene in an insulin-dependent diabetic man. Recognition and management of this rare syndrome in the setting of a common disease is discussed.
To examine the outcome of 23 consecutive patients with Fournier's gangrene.
Patients' charts were reviewed retrospectively from all those treated for Fournier's gangrene between July 1994 and July 1997 at the UCLA affiliated hospitals.
Twenty-three patients were identified (mean age 51.7 years, range 13-71). The aetiologies included perirectal abscess (43%), urethral stricture (30%), scrotal abscess (21%) and unknown (4%). Predisposing factors included diabetes mellitus (43%), steroids or chemotherapy (21%), alcohol abuse (43%), malignancy (26%) and radiation therapy (9%). All 23 patients initially received wide debridement and placement of a percutaneous suprapubic tube. At the time of the first surgery, total scrotectomy was required in all, colostomy in 17% and penectomy in 4%. An additional 35% required eventual colostomy and an additional 9% required a penectomy. Patients underwent repeat debridement a mean of 2.5 times; the overall survival was 96%.
Survival can be improved in patients with Fournier's gangrene by combining aggressive surgical and medical management. The keys to successful outcome included a high index of suspicion, prompt fluid resuscitation, rapid initiation of broad-spectrum antibiotics, a multidisciplinary approach, early surgical intervention with radical debridement, haemodynamic support in an intensive care setting, and frequent repeat operative debridement.
We review the use of hyperbaric oxygen therapy in urology, and present the mechanisms of hyperoxia action in whole body hyperbaric chamber treatments, patient outcomes and patient selection criteria.
The literature on hyperbaric oxygen use in urology was reviewed.
Hyperbaric oxygen is a treatment alternative for patients with an underlying ischemic process unresponsive to conventional therapy. Specific factors which may influence patient selection of hyperbaric oxygen include cancer and absolute contraindications of active viral disease, intercurrent pneumothorax and treatment with doxorubicin or cisplatin. This technique is particularly useful in the treatment of intractable hemorrhagic cystitis secondary to pelvic radiation therapy. Further investigation of the efficacy of hyperbaric oxygen is warranted for patients with necrotizing fasciitis (Fournier's gangrene), posttraumatic ischemic injury and/or impaired wound healing.
Hyperbaric oxygen is a therapeutic alternative which complements the surgical and medical options for select patients.
Gonadal possession of the vascular supply and anatomical separation from the surrounding fascia generally spare the testes from Fournier's gangrene. To our knowledge the presence of air on plain film of the kidneys, meters and bladder in the setting of necrotizing fasciitis has not been previously described. We report on a patient with Fournier's gangrene and plain film evidence of testicular involvement.
Magnetic resonance imaging and ultrasound are the imaging modalities recommended in the early diagnosis of Fournier's gangrene. Because of the high mortality of this inflammatory disease early diagnosis is essential to initiate adequate surgical and medical treatment. In the clinical literature only a handful of cases, in which diagnosis of Fournier's gangrene is based on MRI findings, have been reported; therefore, we report another case which shows the ability of MRI especially to determine the point of origin and extension of disease.
Fournier's gangrene (FG) is a fatal infectious disease with necrotic fasciitis of the external genitalia. This disease persists to this day in spite of recent advances in antibiotics. Although fewer than 100 cases have been reported in Japan, we have treated six cases in the last 4 years. The patients consisted of five men and one woman, with an average age of 47.5 years. All patients received surgical treatment including incisions, aggressive debridement, drainage, irrigation, and antibiotic therapy. Two patients, who suffered from underlying diseases of diabetic nephropathy and inclusion body myositis, died. These findings confirm the fact that FG requires a prompt diagnosis and immediate surgical treatment.
Presented here are 23 patients with Fournier's gangrene who were treated between 1990 and 1999 in the departments of general surgery, urology, and plastic and reconstructive surgery. Patients were reviewed retrospectively and are discussed according to age, gender, bacteriology, etiology, treatment, and outcome in the light of the current literature.
This study presents the authors' experience using the anterolateral thigh fasciocutaneous flap for complex perineal and scrotal reconstruction. Anterolateral thigh fasciocutaneous island flaps were performed in seven patients between January and June of 2000 (six male, one female; mean age, 52 years; age range, 9 to 72 years). Four of the seven patients had scrotal or perineal defects after multiple debridements for Fournier's gangrene. Two of these four had exposed testicles. Three flaps were used for recurrent ischial ulcers. A true septocutaneous perforator (type 1) running between the rectus femoris and the vastus lateralis muscles was found in only two patients. In four patients, the cutaneous perforators were found to be intramuscular, originating from the descending branch (type 2). In the other patient, the musculocutaneous perforator originated from the lateral circumflex femoris artery independently (type 3). In these cases, intramuscular dissections were performed to follow each perforator to its main trunk. Mean follow-up was 8 months (range, 5 to 10 months), and all flaps survived. Three patients developed minor wound dehiscence in the posterior aspect of the perineal wound because of fecal contamination and skin maceration. Both wounds healed secondarily. Scrotal reconstruction with the anterolateral thigh flap gave an excellent aesthetic result. The authors conclude that the anterolateral thigh flap is a reliable flap for perineoscrotal reconstruction.
To date, there have been no reports of Fournier's gangrene following penile self-injection of cocaine. We report a case of cocaine-induced Fournier's gangrene requiring parenteral antibiotics followed by primary surgical debridement and delayed reconstructive procedure of penile skin.
A 16-year-old boy with refractory acute myelogenous leukemia developed Fournier's gangrene as an early complication after two-antigen HLA-mismatched unrelated cord blood stem cell transplantation. On day 25 after the transplantation, he noted abrupt onset of penile swelling with miction pain. The penile inflammation rapidly extended posteriorly to involve the scrotum and perianal tissues, inferiorly to involve the thighs, and superiorly up the lower abdominal region within the next 36 h, and he died from sepsis on day 27. Fournier's gangrene presenting as a genitoperineal necrotizing fasciitis should be considered as a potential complication in umbilical-cord blood recipients in the cytopenic post-transplant phase.
An inguinal and perianal localization of Fournier's gangrene (FG) in a 15-month-old boy as a complication of the varicella infection is discussed. This is the first presentation of the disease as a complication of the varicella rashes. There were already 57 pediatric FG cases resulting from other causes that had been presented in the medical literature.
To evaluate, in a population of patients with very high risk of diabetes, the natural history of Fournier's gangrene (FG) and to characterize the differences in presentation and outcome.
Patients with FG were identified during a 6-year period at two tertiary care institutions in San Antonio, Texas. The impact of diabetes on presentation and outcome were evaluated and compared with previous series.
We identified 26 patients with FG, of whom 20 (76.9%) had diabetes. Diabetes was the most common risk factor identified and was associated with a younger age. The average hospital stay was not affected by the diagnosis of diabetes. Of 26 patients treated for FG, 3 (11%) died, 1 of whom had diabetes. Although the extent of debridement required was greater among diabetics, the average number of debridements required was not increased (2.55 in diabetic and 2.4 in nondiabetic patients).
Although diabetes is a risk factor for FG, the outcome is not affected by this diagnosis.
Fulminant necrotizing soft-tissue infection of the external genitalia and perineum (Fournier's gangrene) occurred in a patient with severe alcoholic hepatitis. By means of radical débridement and disinfection of the necrotizing tissue, use of broad-spectrum antibiotics and prednisolone, and other supportive measures, Fournier's gangrene and severe alcoholic hepatitis eventually subsided with broad skin defects in the waist and external genitalia. Later, the skin defects were successfully reconstructed with skin grafts. Although the route of bacterial intrusion could not be defined, Fournier's gangrene presumably developed in a background of impaired immunological defences, principally associated with habitual massive alcohol consumption and profound liver dysfunction. This present case highlights not only the underlying immunocompromised condition but also the need for concern regarding the urogenital and anorectal areas as potential foci of life-threatening infection in patients with liver dysfunction, especially when related to alcohol intake.
Major scrotal defect with exposed testes and/or spermatic cords are a challenge for the reconstructive surgeon. The bacterial flora of the perineum, difficulty of immobilisation and the contour of the testes make testicular cover a difficult task [Br. J. Plast. Surg. 41 (1988) 190]. Traditional approaches have used simple skin grafts or if not feasible, multi-staged procedures with initial burying of the testes under delayed medial thigh flaps. Better techniques then evolved to permit early single-staged coverage using flaps rather than skin grafts in these usually contaminated and unsuitable wounds to improve the cosmetic outcome of the reconstruction and reduce patient discomfort and hospital stay. Muscle flaps represent an excellent reconstruction option in the contaminated perineum especially in patients with impaired ability to deal with infection such as diabetic or toxic patients. We present two cases of reconstruction of the scrotum using simple, reliable single-stage muscle flap techniques with good aesthetic results and review the literature.
Wide excision of extramammary Paget's disease of the penoscrotal region may leave large defects that cannot be closed easily. The authors describe their experience with a series of 6 patients in whom reconstruction of the scrotal defect was undertaken using the scrotal remnant raised as a stretchable musculocutaneous flap. It was observed that as little as a third of the residual scrotum could be expanded to resurface the entire scrotum. All flaps survived completely. Severe scrotal edema and ecchymosis were observed in 1 patient but the symptoms resolved completely with Trendelenburg positioning. The penile defects were resurfaced individually with thick skin grafts. Good-quality take with no chordee was observed in all patients after initial reconstruction. One patient developed penile contracture after reexcision of recurrent disease. Mean follow-up was 22 months (range, 3-60 months). Large defects of as much as two thirds of the scrotum may be reconstructed successfully using the tissue-expanding scrotal musculocutaneous flap.
Fournier's gangrene is a necrotizing fasciitis of the scrotum or perineum that may extend by way of the fascial planes to the penis and the anterior abdominal wall up to the clavicles, buttocks, or lower extremities. It is a life-threatening progressive disease that requires aggressive antibiotic therapy and early radical debridement. Sparganosis is a parasitic infection that occurs principally in cats and dogs, but human infestations have been reported, albeit rarely. Recently, we experienced a case of Fournier's gangrene associated with sparganosis in the scrotum, which was treated with antibiotics and extensive debridement including removal of a white, flat, shiny sparganum worm.
- Asopa
- Zenda
- Tiwari