Reconstruction of penile skin loss by superficial circumflex iliac perforator (SCIP) pedicled flap after Fournier's gangrene.

INTRODUCTION: Fournier's gangrene is a serious pathology with a high mortality rate. Treatment requires a large debridement of necrotized tissues, conducing to a skin loss, requiring a reconstruction, which may involve different surgical techniques, depending on the context as well as the size and location of the skin loss. The most common covering technique uses split-thickness skin grafting, which however presents a risk of contracture. CASE: Our 63 years old patient presented a Fournier's gangrene, leading to pubic and circular penile skin defects after multiple debridements. We decided to practice a right superficial circumflex iliac perforator (SCIP) pedicled flap to reconstruct the penile skin sheath. The flap was rotated 180 degrees and rolled around the penis. DISCUSSION: The inguinal pedicle flap is described for penile reconstruction, the SCIP flap for perineal reconstruction, and even bilateral SCIP flaps for performing phalloplasty, but SCIP pedicled flap is not already described for isolated penile skin sheath reconstruction. Skin loss in our patient was not extensive, permitting us to perform this surgical technique. To go further, note the possibility of carrying out this reconstruction by a super-thin SCIP flap, as a pure skin graft flap. CONCLUSION: The SCIP pedicled flap seems us to be a safe technique for penile skin reconstruction and a good alternative to the usual skin grafts, especially regarding the lower risk of contracture, and low donor-site morbidity.

Reconstruction with bilateral posteromedial thigh (PMT) flaps after Fournier's gangrene.

Fournier gangrene (FG) is a deadliest condition affecting genitoperineal area in predisposed patients. A late diagnosis, thus a delayed surgical treatment, leads often to death. LRINEC score and CT scan can help in suspect, despite definitive diagnosis needs surgical exploration and histological findings. Furthermore, FG determines wide defects of genitoperineal area, thus reconstructive surgery is pivotal to restore form and function of the affected patient. Aim of this article is to discuss the use of posteromedial thigh (PMT) fasciocutaneous flap in FG reconstruction, based on authors' personal experience. A case report of a 63-year-old obese and diabetic man is presented. Two PMT flaps (10 x 17cm2) were harvested to cover a complete scrotal defect (20 x 40cm2), while penis integuments defect was treated with a two-staged surgery (dermal substitute application and skin graft). Follow-up at 4 months showed a successful outcome of PMT flaps reconstruction, with preservation of testes vitality, despite one of the flaps developed distal necrosis that was treated with further debridement and skin graft. The authors experience is followed by the decision-making process based on a literature review that led to the choice to use PMT flaps to achieve reconstruction. Furthermore, alternative flaps to treat FG, each of them with pros and cons, are discussed, despite there is not a gold standard treatment and every option must be tailored to the patient. KEY WORDS: Fournier gangrene, Genital reconstruction, Infection, Necrotizing fasciitis, Posteromedial thigh flap, Perineum reconstruction.

Fournier's Gangrene under Sodium-Glucose Cotransporter-2 Inhibitors Therapy in Gynecological Patients.

Fournier's gangrene (FG) is a serious pathology of the soft tissues and fascia of the perineum and genital region with a high morbidity and mortality rate. In recent years, the SGLT-2 inhibitor oral antidiabetic has been related to this entity. According to the new warnings from the main drug agencies, a compilation of cases has been initiated to establish or deny a possible causal relationship. Most of these cases have been reported in men. However, it is important not to underestimate this entity in the gynecological field, since it is extremely serious and requires intense and rapid aggressive treatment based on surgery and empiric antibiotherapy. Later, some cares are needed to involve surgical reconstruction of the defects introduced by debridement. As a result of the low incidence of FG, clinical trials' data may be insufficient to robustly assess this issue because of the limited numbers of participants. Real-world evidence may help to clarify the association between SGLT2i and FG. The aim of this review is to describe and compare the reported cases of GF in diabetic women who received SGLT2 inhibitors as antiglycemic agents.

Fournier's gangrene: its management remains a challenge.

Fournier's gangrene (FG) is a rapidly progressive necrotizing bacterial dermo-hypodermitis of the perineum and external genitalia. It represents a real medical and surgical emergency requiring multidisciplinary care. Our study was based on the retrospective analysis of 18 cases of FG, collected in the Department of General and Visceral Surgery of Fattouma Bourguiba University Hospital in Monastir over an 18-year period extending from January 2000 to December 2018. Our series included 18 cases of FG collected over an 18-year period, an annual incidence of one case per year. The average age of our patients was 58 years (36 to 77). The male prevalence was clear. Diabetes and old age were found to be the major risk factors. The treatment was based on an aggressive surgical debridement remains to be the cornerstone of therapy and is commonly preceded by patient preparation for the surgical act by perioperative resuscitation and broad-spectrum antibiotic therapy, possibly accompanied by hyperbaric oxygen therapy (HBOT). The vaccum assisted closure (VAC) therapy is also used, which is a non-invasive system that promotes open wound healing. Healing techniques can be once the septic risk is controlled. Dressings topical treatments, such as fatty substances or calcium alginate, in addition to skin grafts, musculo-neurotic or musculo-cutaneous cover flaps can be used. During the follow-up period, no reccurrence occurred in 14 out of the 18 cases (2 patients were lost to follow-up and 2 patients died). A colostomy was closed in 10 out of 11 cases with simple follow-ups. Restorative surgery (partial thickness skin graft) at the perineal level was performed in only one case. Despite the better understanding of its etiopathogenesis, the advent of targeted antibiotic therapy, the establishment of a better codification of surgical procedures, the contribution of hyperbaric oxygenation and reconstruction techniques, mortality rates are still high and FG remains a real health threat, thus constituting a real medical and surgical emergency.

Penile Necrosis as a Presenting Sign of Purpura Fulminans Mimicking Fournier's Gangrene.

ABSTRACT: We report the case of a 63-year-old white man who, 3 days after stent removal of endoscopic drainage of pancreatic cysts, developed a penile necrosis due to purpura fulminans (PF) that has been misdiagnosed as Fournier's gangrene. Penile necrosis was rapidly followed by a lethal multiorgan failure due to disseminated intravascular coagulopathy (DIC), triggered by the subsequent development of a severe acute pancreatitis. PF describes a rare syndrome involving intravascular thrombosis and hemorrhagic infarction of the skin. Although reports of penile necrosis secondary to various causes are documented in the literature, penile necrosis secondary to PF in the setting of acute pancreatitis is a rare event. Histopathologic studies of the skin showing an occlusive nonvasculitic vasculopathy are the first step to achieve an accurate diagnosis.

Gangrena de Fournier e inhibidores de la SGLT2: a propósito de un caso / Fournier's gangrene and SGLT2 inhibitors: A case study

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Pharmacovigilance assessment of the association between Fournier's gangrene and other severe genital adverse events with SGLT-2 inhibitors.

Objective: Sodium glucose cotransporter-2 inhibitors (SGLT2i) exert cardiorenal protection in people with diabetes. By inducing glycosuria, SGLT2i predispose to genital infections. In addition, rare occurrence of Fournier's gangrene (FG) has been reported. We aimed to investigate such association through the U.S. Food and Drug Administration (FDA) adverse event (AE) reporting system (FAERS). Research design and methods: We mined the FAERS up to 2018q3 (before FDA warning about SGLT2i-associated FG) to retrieve reports including FG as an AE and SGLT2i as suspect or concomitant drugs, and calculated proportional reporting ratios (PRR). Results: We retrieved 47 cases of FG and 17 cases of other severe AEs of the genital area associated with SGLT2i. Patients with FG were ~10 years older than those with other severe genital AEs. Overall, 77% occurred in men. Three patients were concomitantly treated with systemic immunosuppressive drugs. Increased reporting frequency emerged for SGLT2i compared with other drugs, with a PRR ranging from 5 to 10. The disproportional reporting of FG with SGLT2i remained robust and consistently significant when restricting to the period when SGLT2i were available, to reports filed for glucose-lowering medications or for drugs with the diabetes indication, and after refining the definition of FG. FG was disproportionally associated with psoriasis and with the combination of immunosuppressants and SGLT2i. Conclusions: Although causality cannot be demonstrated, SGLT2i may predispose to FG and other severe genital AEs. Since the use of SGLT2i is expected to increase significantly, clinicians should be aware of these severe, although rare, AEs and their predisposing factors.

Potential of hyperbaric oxygen in urological diseases.

Hyperbaric oxygen therapy is a promising medical technology that delivers oxygen to targeted tissues at high pressure to increase the amount of dissolved oxygen in the blood. Over the past three decades, hyperbaric oxygen has been used in a variety of conditions, including radiation-induced tissue injuries, non-healing states with ischemia and malignant neoplasms. In the field of urology, hyperbaric oxygen has also been applied to some pathological conditions (e.g. radiation-induced hemorrhagic cystitis, Fournier gangrene, interstitial cystitis, male infertility, acute kidney injury and urological cancers). In normal and injured tissues, hyperoxia from hyperbaric oxygen therapy contributes to anti-inflammation, angiogenesis through endothelial proliferation, enhanced fibroblastic activity, increased lymphocyte and macrophage activity, and bactericidal effects with the aim of wound repair. In cancerous tissues, the enhanced supply of oxygen into the hypoxic cancer cells can exert inhibitory effects on factors that contribute to their aggressiveness (e.g. cell survival, escape from apoptosis, epithelial-to-mesenchymal transition and tumor immunotolerance), and sensitize the tumor to radiation therapy and chemotherapy. However, further research, including multicenter clinical studies, is essential for determining the role of hyperbaric oxygen therapy in refractory urological diseases that are resistant to conventional therapies.

Rare isolation of Fusobacterium varium from a case of Fournier's gangrene.

Fusobacterium is a gram negative obligate anaerobic bacilli, a normal inhabitant of gastrointestinal tract, oropharynx and female genital tract. Here we report a case of Fourniers gangrene from which Fusobacterium varium has been isolated along with certain other pathogens. There are only a few reported cases of Fusobacterium varium in literature and it has never been reported from Fournier's gangrene. Through this report we intend to shed some light on the pathogenic potential of anaerobes which are considered as normal flora.

Fournier's gangrene: not as lethal as previously thought? A case series.

BACKGROUND: Fournier's gangrene (FG) is a necrotizing fasciitis involving the perineum, external genitalia or perianal area. A rare condition with a historically high mortality rate (20-40%), our objective was to provide an up to date mortality rate for patients treated with multimodal therapy in a tertiary referral centre. METHODS: A retrospective review of a prospective database of FG patients treated at our tertiary referral centre was conducted. The primary end point was survival. Secondary end points included total hospital and intensive care unit (ICU) length of stay (LOS), number and type of procedures as well as considering co-morbidities at presentation as potential predisposing factor. Results were compared to those in current literature. RESULTS: Between 2012 and 2017, 15 patients were diagnosed with FG at our tertiary referral centre. One was excluded as decision to palliate was made at presentation. Of the remaining 14 patients, 13 survived representing a mortality rate of 7%. In surviving patients, total LOS was between 10 and 71 days, with a mean LOS of 36 days and median LOS of 34 days. Eight required ICU with ICU LOS between 1 and 42 days, with a mean of 10 and median of 4. Number of debridement procedures ranged from 3 to 17 with a mean and median of 6. Six patients required adjunctive procedures and 10 required reconstructive procedures. CONCLUSION: While a prolonged admission and multiple operations are expected, early diagnosis and aggressive multimodal treatment may result in a significantly better survival outcome than those quoted in previous literature.

Sudden unexpected death due to Fournier gangrene.

Fournier gangrene is a rare fulminant necrotizing infection of the skin and soft tissue of the perineum that may result in rapid death. We describe the autopsy case of a 70-year-old female with uncontrolled diabetes mellitus who was found unexpectedly dead in her house where she lived with her dog. Examination of the body revelaed a deep necrotic ulceration of the perineum with exposure of the underlying deep muscles that was initially misinterpreted by police officers as post mortem animal predation. Medicolegal examination and histological and microbiological analyses eliminated this hypothesis and the diagnosis of septic multiorgan failure due to necrotizing fasciitis was retained as a cause of death.

Factors Affecting Mortality in Fournier Gangrene: A Single Center Experience.

BACKGROUND: The objective of this study was to determine the clinical and laboratory features affecting mortality in Fournier gangrene. PATIENTS AND METHODS: This retrospective case control study was designed to evaluate patients treated for Fournier gangrene in our center between 2010 and 2018. Those patients were divided into two groups: discharged patients (group 1) and deceased patients (group 2). Comparisons were made regarding clinical and demographic features; leukocyte, neutrophil and lymphocyte count results; neutrophil to lymphocyte ratio (NLR); Fournier's Gangrene Severity Index (FGSI) scores; number of debridements; complications; and mortality rates. RESULTS: Twenty-three patients (19 males, 4 females) were evaluated; mean age was 65.91 ± 16.34 years. The most common cause of the disease and comorbidity were perianal abscess (n = 14; 60.9%) and type 1 diabetes mellitus (n = 11; 47.8%), respectively. Escherichia coli was the pathogen identified most often (n = 17; 73.9%). The total mortality rate was 21.7% (n = 5). Neutrophil to lymphocyte ratio, FGSI, number of debridements, and complication rates were higher in group 2 (p < 0.05). There was a substantial difference between the groups regarding perianal abscess in group 1 and rectum cancer in group 2 (p < 0.05). CONCLUSION: In conclusion, it was believed that the mortality rate could be predicted by combining the NLR value with the FGSI score.