Summary
Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.
Keywords
Fournier’s gangrene is a type of necrotizing soft-tissue infection affecting the external genitalia or perineum. In contrast to the initial description by French venereologist Jean Fournier in 1883, the condition is not limited to males. There are multiple options for Fournier gangrene reconstruction ranging from healing by secondary intention to regional or free flap reconstruction.
This study took place at Guys and St Thomas’ NHS Foundation Trust (GSTT). GSTT is a large NHS trust based in London, United Kingdom. With a catchment area of over 1 million people across south London, it also offers a large tertiary plastics and reconstructive surgery unit with over 20 consultant surgeons. This retrospective study was intended to clarify our practice and thus promote reflection of current management and compare our reconstructive options to that used in the literature.
Methods
Retrospective data collection was performed for January 2010 to January 2020 using our operative booking database under the criteria ‘debridement.’ All debridement operation notes during this period were assessed and any Fournier’s gangrene cases were included. The anatomical region involved was recorded and the reconstruction used for each region recorded separately. Any secondary reconstruction was also recorded during this period.
Ethical approval: not required.
Results
The study looked at 34 Fournier's gangrene cases that occurred over a 10-year period, with an average age of 58 and a 79% male gender breakdown. Diabetes was the comorbidity that was most common (50%) and a 54-day stay was the average. Skin grafting was the main reconstruction option (74%) and only one patient died within 30 days of diagnosis.
Reconstruction options were presented by anatomical area, with skin grafts commonly used for scrotal defects in males. Skin grafts were used in 90% of penile involvement cases, with two requiring revisions due to contracture. Vulval involvement was less common, with four cases requiring reconstruction, two with skin grafts, and one with bilateral IGAP flaps.
Three cases needed secondary reconstruction (9%), involving urethral dilatation, scar revision, and excision of a skin graft with full-thickness skin graft application. Only one case required formal urethroplasty. Skin grafting was the preferred method for perineal involvement (88%), with only one case needing a perforator flap. Scrotal defects did not require any perforator flaps.
Discussion
Fournier gangrene is a severe bacterial infection that requires prompt surgical intervention. The infection can cause extensive damage to the skin and tissue, leading to defects that need to be reconstructed. Reconstruction options vary based on defect size, depth, location, surgeon preference, and patient preference. The primary goal of reconstruction is to reduce morbidity and simplify the procedure.
In this analysis, skin grafting was the primary reconstructive option used in most cases (76%), including scrotal, penile, and vulval defects. Compared to the literature, this is considerably higher than many other studies, with a recent systematic review reporting 22.6% of cases had skin grafting for Fournier defects, with a higher proportion having local or regional flap options (30% compared to our 10%).
1
Our rate of split skin graft (SSG) for scrotal reconstruction of 72% is significantly more than the literature.2
SSGs are simple and quick, with minimal donor site morbidity, and provide functional and cosmetic results like scrotal skin. Primary closure (11%) was low in comparison to other studies, and SSG was preferred in younger patients to avoid impairing fertility.3
The application of FTSG to penile defects as opposed to SSG would reduce the need for revision, due to the lesser degree of secondary contracture by FTSG. In cases of extensive penile and urethral involvement, urinary diversion through a suprapubic cystostomy should be considered.
4
Our rate of female cases (21%) is a slightly higher female involvement than in the literature, whereby the ratio of male-to-female involvement is reported to be over 10:1, ours being a 5:1 ratio.
5
The fact that such a high proportion (57%) involved the vulva compared to 38% penile involvement of men in this series, combined with the fact it was the only case requiring regional flap reconstruction, is perhaps reflective of the severe course of Fournier in female patients.Consider patient's age and medical conditions when choosing a reconstructive option for Fournier gangrene. SSG is often the preferred option due to its simplicity and quickness, as well as its ability to result in a shorter general anesthesia time, particularly for patients with comorbidities. SSG's efficiency and safety make it a highly viable solution in these complex cases (Table 1, Table 2).
Table 1Primary reconstruction used presented according to the reconstructive ladder (note in some cases more than one option is used).
| Cases | Secondary intention | Primary Closure | Skin Graft | Local flap | Regional flap |
|---|---|---|---|---|---|
| N = 34 | 5 (15%) | 2 (6%) | 25 (74%) | 2 (6%) | 1 (3%) |
Table 2Reconstruction divided by anatomical region (note most cases involved more than one region but each region is assessed separately).
| N | Secondary intention | Primary closure | Skin Graft | Local flap | Regional flap | Secondary Reconstruction (%) | |
|---|---|---|---|---|---|---|---|
| Male | 27 | - | - | - | - | - | 3 (11%) |
| Perineal | 18 | 1 | 0 | 16 | 1 | 0 | - |
| Scrotal | 18 | 2 | 2 | 13 | 1 | 0 | - |
| Penile | 10 | 1 | 0 | 9 | 0 | 0 | - |
| - | - | - | - | ||||
| Female | 7 | - | - | - | - | - | 0 (0%) |
| Perineum | 7 | 1 | 0 | 6 | 0 | 0 | |
| Vulva | 4 | 1 | 0 | 2 | 0 | 1 (IGAPs) |
Conclusions
This retrospective analysis has provided a useful reflection of our reconstruction of Fournier’s gangrene cases over the last decade. Take-home messages for this series include the fact that a high proportion of defects can be reconstructed using SSG to minimize operative time and donor site morbidity. Finally, where possible, FTSG should be applied to penile defects to prevent secondary contracture and the need for revision surgery.
Funding
None.
Ethical approval
Not required.
Conflicts of interest
None.
References
- Reconstruction of defects after Fournier Gangrene: a systematic review.Eplasty. 2015; 15e18
- Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene.Burns. 2003; 29: 857-862https://doi.org/10.1016/j.burns.2003.07.001
- Surgical reconstruction of the sequelae of penile and scrotal gangrene: a plea for simplicity.Br J Plast Surg. 1984; 37: 354-357https://doi.org/10.1016/0007-1226(84)90078-x
- Meshed unexpanded split-thickness skin grafting for reconstruction of penile skin loss.J Urol. 2004; 172: 976-979https://doi.org/10.1097/01.ju.0000133972.65501.44
- Fournier gangrene in men and women: appearance on CT, ultrasound, and MRI and what the surgeon wants to know.Can Assoc Radiol J. 2020; 71: 30-39https://doi.org/10.1177/0846537119888396
Article info
Publication history
Published online: March 03, 2023
Accepted:
February 21,
2023
Received:
August 30,
2022
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© 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd.
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