Management of Fournier's gangrene in a newborn: A rare case report and literature review.

INTRODUCTION: Fournier's gangrene (FG) in neonates is less common than in adults, but this case can lead to a poor prognosis. FG is a disease of the genital, perianal, and perineal areas characterized by necrotizing infections. Here, we report a case of a 24-day-old male infant diagnosed with Fournier's gangrene involving the scrotum. CASE PRESENTATION: The patient presented with scrotal swelling, fever, erythema, and insect bites on the penile tip that had gradually extended to the proximal area and bilateral scrotum. On physical examination, indurated grayish and blackish-brown scrotal skin with sharp distinction from the surrounding normal skin, erythema, purulence, ulceration, and necrotic tissue were observed. Abdominal X-ray and scrotal ultrasonography revealed gaseous distension of the scrotal region, free fluid on bilateral testes, and enlargement of bilateral testicles. Immediate surgical debridement, along with broad-spectrum antibiotics, was initiated, and a microbiological culture identified the presence of Pseudomonas aeruginosa. The patient demonstrated the completed healing of the surgical wound after thirty days of surgical intervention. DISCUSSION: Fournier's gangrene in neonates is a sporadic case. Our patient presented with multiple predisposing factors, including insect bites and poor hygiene, underscoring the need for heightened clinical suspicion in vulnerable populations. Prompt recognition and intervention are critical, given the rapid progression of FG. CONCLUSION: This case underscores the importance of timely diagnosis and early initiation of surgical and medical interventions in neonatal Fournier's gangrene, particularly in cases involving the scrotum.

Big bladder stone accompanied by big posterior urethral stone: A management of rare case report.

INTRODUCTION AND IMPORTANCE: Urinary tract stones are a common disease, but concurrent large-size stones in the bladder and urethra are rare. This phenomenon can lead to obstruction, infection, and other complications. We reported the management of a rare case of a giant bladder stone accompanied by a big posterior urethral stone. CASE PRESENTATION: A 36-year-old man with a chief complaint of not being able to have spontaneous micturition, frequent expulsion of stones from the penis, and a history of hematuria. Bladder examination revealed a giant bladder stone of 1278 Hounsfield Unit (HU) with a size of 4.1 × 7.2 cm, and urethral examination revealed a stone of 1275 Hounsfield Unit (HU) with a length of 4.3 × 4.2 cm, without mass. This patient underwent vesicolithotomy and urethrotomy. The evaluation showed spontaneous micturition and dissolved hydronephrosis. CLINICAL DISCUSSION: Urinary tract stone management primarily involves endourology or open surgery. For smaller stones (<5-6 mm), medication is sufficient, as they often pass spontaneously. Larger stones may require interventions like vesicolithotomy or urethrotomy. Vesicolithotomy is preferred for complex or large bladder stones, while urethrotomy is performed if the stone location is palpable or seen on imaging. These procedures are practical options for general surgeons in first-level hospitals. CONCLUSION: Concurrent large bladder and urethral stones are uncommon. Endourology or open surgery is typically employed. Treatment selection should be personalized to individual patient assessment to mitigate potential complications effectively.

Evaluating prognostic indicators for in-hospital mortality in Fournier's gangrene: a 7-year study in a tertiary hospital.

BACKGROUND: Fournier's Gangrene Scoring Index (FGSI), Simplified FGSI (SFGSI), Uludag FGSI (UFGSI), Laboratory Risk Indicator for Necrotizing (LRINEC), Neutrophil-Lymphocyte ratio (NLR), and Platelet-lymphocyte ratio (PLR) have been devised to assess the risk of mortality in Fournier's Gangrene (FG) patients. However, the effectiveness of these indicators in predicting mortality at the time of admission remains uncertain. The aim of this study is to assess the prognostic efficacy of FG's various indicators on in-hospital mortality. METHODS: This study analyzed 123 patients from Dr. Soetomo General Hospital's emergency department in Indonesia from 2014 to 2020. Data included demographics, wound cultures, and parameters like FGSI, UFGSI, SFGSI, NLR, PLR, and LRINEC. In-hospital mortality status was also recorded. The data was subjected to comparative, sensitivity, specificity and regression analyses. RESULTS: In our study of 123 patients, the median age was 52, with a mortality rate of 17.9%. The majority of patients were male (91.1%) and the most common location was scrotal (54.5%). Non-survivors had a shorter median stay (6.5 days) compared to survivors (14 days). Diabetes was the most prevalent comorbidity (61.8%). The highest sensitivity and specificity were found in FGSI and UFGSI indicators. Multivariate logistic regression identified LoS and FGSI as independent predictors of mortality. CONCLUSIONS: FGSI and UFGSI, upon admission, demonstrated the highest sensitivity and specificity, with hospital stay duration and FGSI as key mortality determinants.

Economic Evaluation of COVID-19 Screening Tests and Surveillance Strategies in Low-Income, Middle-Income, and High-Income Countries: A Systematic Review.

BACKGROUND Economic evaluation of the testing strategies to control transmission and monitor the severity of COVID-19 after the pandemic is essential. This study aimed to review the economic evaluation of COVID-19 tests and to construct a model with outcomes in terms of cost and test acceptability for surveillance in the post-pandemic period in low-income, middle-income, and high-income countries. MATERIAL AND METHODS We performed the systematic review following PRISMA guidelines through MEDLINE and EMBASE databases. We included the relevant studies that reported the economic evaluation of COVID-19 tests for surveillance. Also, we input current probability, sensitivity, and specificity for COVID-19 surveillance in the post-pandemic period. RESULTS A total of 104 articles met the eligibility criteria, and 8 articles were reviewed and assessed for quality. The specificity and sensitivity of COVID-19 screening tests were reported as 80% to 90% and 40% to 90%, respectively. The target population presented a mortality rate between 0.2% and 19.2% in the post-pandemic period. The implementation model of COVID-19 screening tests for surveillance with a cost mean for molecular and antigen tests was US$ 46.64 (min-max US $0.25-$105.39) and US $6.15 (min-max US $2-$10), respectively. CONCLUSIONS For the allocation budget for the COVID-19 surveillance test, it is essential to consider the incidence and mortality of the post-pandemic period in low-income, middle-income, and high-income countries. A robust method to evaluate outcomes is needed to prevent increasing COVID-19 incidents earlier.

Massive subcutaneous abscess: A case report of management and source control.

INTRODUCTION AND IMPORTANCE: Postoperative peritoneal infection, a common complication, remains prevalent despite surgical advancements. Acute abdomen necessitates rapid treatment, often presenting with abdominal pain and systemic inflammation. Bladder injuries, potentially leading to sepsis, require immediate surgical intervention. CASE PRESENTATION: We report a case of a 60-year-old man who came with the main complaint of feeling full in his stomach for 7 days, accompanied by non-radiating right lower abdominal pain since one day before hospital admission and a lethargy condition. There are complaints of seepage from the stitch marks on the right stomach, such as yellow urine. Laboratory and physical examination showed the patient in sepsis condition. CT Cystography showed a defect of 0.4 cm on the bladder dome, the contrast leakage into extraperitoneal and intraperitoneal, and tunneling to the right abdominal subcutaneous. The patient underwent subcutaneous abscess, bladder repair, and cystostomy. One month after surgery, the patient had normal micturition. CLINICAL DISCUSSION: Acute abdominal pain is one sign of emergency surgery. It can be caused by infection, inflammation, vascular occlusion, or obstruction. Physical and laboratory examination of the patient showed a sepsis condition. CT Cystography showed the presence of bladder rupture and subcutaneous abscess. The only management is surgical exploration for infection source control. CONCLUSIONS: This case underscores the importance of prompt diagnosis and comprehensive management, involving surgical intervention and targeted antibiotics, for sepsis-related complications post-TURP and bladder repair, necessitating a multidisciplinary approach for optimal outcomes and complication prevention.

Management of high-grade pediatric renal trauma in tertiary referral hospital in Indonesia: A case series and literature review.

INTRODUCTION AND IMPORTANCE: Genitourinary tract injuries constitute 10 % of all traumas, with renal injuries being common in pediatric cases due to reduced perirenal fat and abdominal wall muscle development. However, very few reports of pediatric renal trauma in Indonesia have been reported. In this case series, We present a case series of high-grade renal injury and review the literature on pediatric renal trauma in Indonesia. CASE PRESENTATION: We present four cases with renal trauma as the subjects of this case study. The 13-year-old boy, who was the initial patient, complained of hematuria and abdominal pain after falling from a tree. The second patient, the 13-year-old boy, presented with left lower back pain and hematuria after being elbowed in the left waist. The third patient, a 14-year-old boy, had been in a motorcycle accident and got grade 5 renal injury according to AAST classification. The final case involved a 4-year-old boy who experienced recurrent hematuria caused by a pseudoaneurysm following blunt renal trauma. DISCUSSION: Trauma is the leading cause of morbidity and mortality in children, with approximately 3 % of children assessed in pediatric hospital trauma departments having had trauma. With appropriate management according to guidelines, mortality can be avoided. CONCLUSION: The case series highlights the significance of treating pediatric renal trauma patients individually according to their hemodynamic state and degree of impairment.

The relationship between income, health insurance, and employment status as prognostic indicators of bladder cancer: A survival analysis.

BACKGROUND: Bladder cancer (BC) is one of the health problems. Socioeconomic status (SES) may correlate with patient treatment, possibly impacting patient prognosis. This study aimed to determine the relationship between income, health insurance, and employment status as prognostic indicators of BC. METHODS: A retrospective observational study for patients diagnosed with BC in a hospital during the 5-year period between January 2019 and December 2023. Kaplan-Meier test analysis was used to generate overall survival curves stratified by income, employment status, and health insurance. Multivariate Cox proportional-hazards regression was used to identify factors associated with worse overall survival. RESULTS: The results of the analysis on 219 patients showed no difference in patient survival based on income (p>0.05), while employment status and health insurance showed significant difference in patient survival (p<0.05). Moreover, there were 99 (45.2%) patients died, with the average patient being 58 years old and dominant in male patients. CONCLUSIONS: Prevention of poor outcomes in patients needs to pay attention to certain characteristics, particularly for the loweconomic patients without appropriate national health insurance coverage.

Endoscopic combined intrarenal surgery for successful removal of an encrusted ureteral stent and multiple renal stones in solitary kidney: A case report.

INTRODUCTION AND IMPORTANCE: Several endoscopic procedures have been performed to clear stones in the kidney. A potential technique called endoscopic combined intrarenal surgery (ECIRS) is a practical option for treating complex kidney stones. Hereby, we report a neglected double j (DJ) stent and recurrent multiple kidney stones treated by ECIRS. CASE PRESENTATION: A 56-year-old female complained of right flank pain one week ago, which worsened within one day before hospital admission. She underwent DJ stent insertion one year ago because of residual stones after right percutaneous nephrolitothomy (PCNL) but was lost to follow-up. There was a history of left nephrectomy, leaving the patient with only a right kidney. A x-ray kidney ureter bladder (KUB) evaluation showed multiple irregular radiopaque shadows. A computed tomography (CT) scan detected numerous stones in the right kidney. The patient underwent ECIRS to remove the DJ stent and clear multiple stones in the right kidney. Following the surgery, the patient was discharged from the hospital on the fourth postoperative day with no complications and residual stone. CLINICAL DISCUSSIONS: ECIRS is a technique that combines a simultaneous antero-retrograde approach to the kidney and aims to resolve nephrolithiasis in one step and with one access. The ECIRS procedure could be considered in cases of complex multiple stone nephrolithiasis. ECIRS could widen the operative vision, thus helping to clear difficult kidney stones. CONCLUSIONS: The ECIRS technique could provide successful and safe management of recurrent multiple kidney stones and encrusted, neglected DJ stents in a solitary kidney patient.

When a non-inflatable implant breaks the penis: A case report of penile fracture due to an unusual penile implant.

INTRODUCTION AND IMPORTANCE: Penile fracture is a relatively uncommon condition that most commonly results from blunt trauma during sexual intercourse, forced flexion, masturbation, or rolling over. However, other causes are also possible. It is a catastrophic illness to the patient's organic and psychological health. CASE PRESENTATION: We report a case of a 43-year-old male patient who sustained a penile fracture due to the presence of a toothbrush implant. No urethral injury was documented. The patient underwent surgical repair, and one month post-surgery, exhibited no deformity and had a normal sexual and voiding function. CLINICAL DISCUSSION: Penile fracture is most commonly caused by blunt trauma during sexual intercourse. While it has not been documented in the literature, penile implants may increase the incidence of penile fractures. Clinical examination and urethrography confirmed the absence of urethral injury. In cases where a penile fracture is suspected, the only management is surgical exploration. This approach has resulted in the lowest rate of negative long-term sequelae and does not negatively impact the patient's psychological well-being. CONCLUSION: Penile fracture is a rare but serious condition that can result from the presence of an unstandardized implant. It is not close to the incidence of penile fracture for unstandardized prosthesis as even the standardized implant can get fracture when counter to high velocity. To avoid functional and morphological abnormalities, surgical exploration is recommended as the primary course of treatment.

Pediatric genitourinary injuries: 7-year experience at the largest tertiary referral hospital in Eastern part of Indonesia.

INTRODUCTION: The anatomical variations between children and adults render pediatric patients more prone to urogenital trauma. However, it is not known for certain whether children are more prone to genitourinary trauma than adults. The aim of the study is to scrutinize the characteristic of pediatric genitourinary trauma at, the largest tertiary hospital in Eastern part of Indonesia. STUDY DESIGN: The design of the study was analytic retrospective gathering medical records of all pediatric patients with urogenital trauma with total sampling. The number of patients, ages, genders, etiology, locations, and management were collected. Data was statistically analyzed using SPSS®, and p < 0.05 was considered statistically significant. RESULTS: We found 13.5 (10-15.5) years as the median age in our 60 samples. Boy (75.00%), renal trauma (56.67%), abdominal and pelvic trauma (96.67%), traffic accident (91.67%), suprapubic catheterization (52.17%), and hemodynamically stable (91.67) was among the majority. We also found that non-operative management was in majority. Statistical analysis demonstrated significant differences for management and grade of injury (p < 0.05). DISCUSSIONS: This is, to the best of our knowledge, the first study of genitourinary injuries in children who were treated at a tertiary hospital in Indonesia during the course of the 7-year research period. The limitations of this study are retrospective character and conducted in single institution. CONCLUSION: The highest incidence of pediatric urogenital trauma is renal trauma due to traffic accident, which often multitrauma. Future prospective multi-center studies should be done to corroborate the results.

Comparison of different scoring systems for predicting in-hospital mortality for patients with Fournier gangrene.

PURPOSE: To compare different scoring systems for predicting in-hospital mortality in patients with Fournier gangrene (FG). METHODS: A comprehensive literature search was performed to find all scoring systems that have been proposed previously as a predictor for in-hospital mortality in patients with FG. Data of all patients with FG who were hospitalized in one of Indonesia's largest tertiary referral hospitals between 2012 and 2022 were used. The receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of the scoring systems. RESULTS: Ten scoring systems were found, i.e., Fournier's Gangrene Severity Index (FGSI), Uludag FGSI, simplified FGSI, NUMUNE Fournier score (NFS), Laboratory Risk Indicator for Necrotizing Fasciitis, age-adjusted Charlson comorbidity index, sequential organ failure assessment (SOFA), quick SOFA, acute physiology and chronic health evaluation II, and surgery APGAR score (SAS). Of 164 FG patients included in the analyses, 26.4% died during hospitalization. All scoring systems except SAS could predict in-hospital mortality of patients with FG. Three scoring systems had areas under the ROC curve (AUROC) higher than 0.8, i.e., FGSI (AUROC 0.905, 95% confidence interval (CI) 0.860-0.950), SOFA (AUROC 0.830, 95% CI 0.815-0.921), and NFS (AUROC 0.823, 95% CI 0.739-0.906). Both FGSI and SOFA had sensitivity and NPV of 1.0, whereas NFS had a sensitivity of 0.74 and an NPV of 0.91. CONCLUSION: This study shows that FGSI and SOFA are the most reliable scoring systems to predict in-hospital mortality in FG, as indicated by the high AUROC and perfect sensitivity and NPV.

Giant long-standing urethral calculus without urinary retention: A case report.

INTRODUCTION AND IMPORTANCE: In this case report, we found a giant urethral stone that lasted for ten years without urinary retention and was admitted to the hospital with a non-urinary main complaint. CASE PRESENTATION: We reported a 53-year-old patient, initially admitted to the emergency room because of decreased consciousness. Notably, the patient also presented with a bulged suprapubic area. Careful examination of the external genitalia pointed to palpable, large-sized calculus proximal to the external meatus. The patient's relatives acknowledged that the stone had been present for ten years, but he could void it spontaneously before admission. The imaging series (KUB X-Ray, Head CT, TAUS) confirmed the diagnoses of brain hemorrhage, bilateral hydronephrosis, and a stone at the navicular fossa. Sequential extra-ventricular drainage and dorsal meatotomy were performed under general anesthesia, resulting in a good local condition. We successfully extracted 4 × 2 cm calculous from the patient's urethra, and the hydronephrosis resolved after the extraction. CLINICAL DISCUSSION: The patient has mild hydronephrosis due to chronic urinary retention and LUTS from the giant urethral stone. The stroke to the dominant hemisphere and insula could lead to acute urinary retention, which worsens hydronephrosis. Immediate diversion of urine by taking stones from the anterior meatus urethra can improve the patient's hydronephrosis condition. CONCLUSIONS: This report demonstrated an interesting case of an impacted giant urethral stone in a critically ill male patient without urinary retention before admission. Prompt evaluation and management are required and should prioritize conditions predisposing patients to severe complications.

Factors for In-Hospital Mortality in 145 Male Patients with Fournier's Gangrene: A 10-Year Observational Study from a Single Tertiary Referral Center in Indonesia.

BACKGROUND Fournier's gangrene (FG) is a potentially fatal necrotizing infection. Due to the rapid progression of the disease, the fatality rate remains high despite advances in therapy. This 10-year observational study from a single tertiary referral center in Indonesia aimed to identify the risk factors for in-hospital mortality from 145 male patients diagnosed with FG. MATERIAL AND METHODS This retrospective cohort study was conducted at one of Indonesia's largest tertiary referral hospitals. The risk factors of in-hospital mortality were analysed using data collected through hospital medical records. All patients diagnosed with FG from January 2012 until December 2021 were included. Outcome measured was sociodemographic factors, comorbidities, laboratory findings, length of stay, culture results, and disease outcome. The microbiological culture was performed on FG lesions isolates. The statistical analysis was conducted using SPSS version 26.0. RESULTS The analysis included 145 male patients with a median age of 52 (IQR, 43-61) years. Of them, 38 (26.20%) patients died. There were more patients with diabetes mellitus (DM) in non-survivor groups compared to survivor groups (76.3% vs 57%, p=0.035). On multivariate analysis, DM and Clostridium perfringens infection were found to be independent factors of in-hospital mortality [adjusted odds ratio (aOR)2.583, 95% confidence interval (CI)=1.061-6.289, aOR 5.982,95% CI=1.241-28.828, respectively]. CONCLUSIONS The mortality rate for FG was considerably high. DM and Clostridium perfringens infection were shown to be independent risk factors for mortality among men.

Paratesticular leiomyoma mimicking an inguinal hernia: A rare case report and literature review.

Leiomyomas are considered as a rare, benign, slow-growing, and smooth muscle tumours which may present in all regions in the body. The presentation of leiomyoma in genitourinary tract specifically in paratesticular region is extremely rare. The patients may present with palpable, and painful mass in the inguinal region hence mimicking the nature of inguinal hernia. Herewith, we report our experience of 36-year-old male which had been referred for the suspicion of incarcerated inguinal hernia manifesting with painful mass in the right inguinal and testicular region. During testicular exploration surgery, a benign tumour was incidentally discovered. The lesions were then surgically removed by performing radical orchiectomy with the pathology result confirmed the presence of paratesticular leiomyoma. The post-operative course was uneventful and the patient was discharged on first post-operative day. The patient remained free from metastases or local recurrence after 12 months of regular follow up. This case report demonstrated a rare presentation of paratesticular leiomyoma with misleading manifestation of inguinal hernia. Careful and tailored investigation should be performed to avoid misled diagnosis of this case.

The efficacy of tissue glue in pediatric circumcision wound approximation: A meta-analysis of randomized controlled trial.

INTRODUCTION: Tissue glue has been examined extensively for its effectiveness in pediatrics, and the findings are good. The purpose of this research was to examine the effectiveness of tissue glue compared to absorbable sutures for wound approximation in pediatric circumcision. METHODS: A systematic review and meta-analysis on children who had circumcision using tissue glue and absorbable suture were done in line with the PRISMA criteria. RevMan 5.4 was used to perform the meta-analysis. The mean differences for continuous and dichotomous data are determined using inverse variance, and the odds ratio is calculated using the Mantel-Haenszel technique. RESULTS: The inclusion criteria were met by six trials containing a total of 817 patients. According to the analysis, tissue glue significantly reduces the duration of the operation (MD - 7.98; 95% CI -12.35, -3.62; p = 0.0003), pain severity (SMD -0.57; 95%CI -0.80, -0.32; p < 0.00001) and the duration of pain (MD - 2.33; 95% CI -2.57, -2.08; p < 0.00001) compared to absorbable suture. However, we found that there was no significant difference in the incidence of postoperative bleeding, infection, dehiscence, or overall complication when comparing tissue glue to traditional suture. CONCLUSION: Our systematic review and meta-analysis using the most recent data suggest that tissue glue usage might reduce the operation time, as well as the intensity and duration of postoperative pain.

Outcome management of Fournier's gangrene cases at tertiary hospital: 7 Years experience.

OBJECTIVE: This study aims to describe the condition of Fournier's gangrene in Dr. Soetomo General Hospital from January 2014 to December 2020. MATERIAL AND METHODS: This study used a retrospective analytic design, by taking data through medical records at Dr. Soetomo General Hospital from January 2014 to December 2020. This study used total sampling with recorded data: age, gender, length of stay, outcome, location, comorbidities, causes, management, culture results, and Fournier's gangrene severity index (FGSI) score. RESULT: Of the 135 subjects collected, it was found that 55.56% were individuals over 50 years of age. About 91.11% were male patients, with some sites being in the scrotum 50.37%. Only 25.19% of patients had no comorbids, while the rest had a history of CKD, hypertension, diabetes, or a combination of these diseases. Bacterial cultures obtained were mostly caused by the Enterobacteriaceae bacteria group (32.59%). Of the subjects we studied who experienced mortality, it was found that all were from the group with FGSI >9. CONCLUSION: From the results of our descriptive study, at a glance, it appears that there is a tendency for the incidence of Fournier's gangrene in the elderly and individuals with comorbidities. And the mortality rate increases with a high FGSI value. So that FGSI could be used as a predictor of mortality in patients with FG.