|Year : 2020 | Volume
| Issue : 2 | Page : 65-71
Penile and scrotal defects post-Fournier gangrene: reconstructive options and challenges in resource limited settings
Chinedu Nnaemeka Ilokanuno1, Titus Osita Chukwuanukwu1, Ezekiel Uchechukwu Nwankwo1, Chidi Kingsley Oranusi2
1 Plastic and Reconstructive Surgery Unit, Department of Surgery, Nnamdi Azikiwe University Awka and Nnamdi Azikiwe University Teaching Hospital Nnewi, Anambra State, Nigeria
2 Urology Unit, Department of Surgery, Nnamdi Azikiwe University Awka and Nnamdi Azikiwe University Teaching Hospital Nnewi, Anambra State, Nigeria
|Date of Submission||01-May-2020|
|Date of Acceptance||01-Oct-2020|
|Date of Web Publication||18-Dec-2020|
Dr. Titus Osita Chukwuanukwu
Plastic and Reconstructive Surgery Unit, Department of Surgery, Nnamdi Azikiwe University Awka and Nnamdi Azikiwe University Teaching Hospital Nnewi, Anambra State
Source of Support: None, Conflict of Interest: None
Introduction: Penile and scrotal defects following necrotizing fasciitis (Fournier gangrene) of the perineum in males can be a source of great morbidity and psychological concern to the patients inflicted with such a problem. In severe cases, it can result in mortality. Reconstruction of extensive defects/ulcers can be challenging in resource limited settings due to limited availability of tools such as doppler ultrasound/stethoscope, loupes, and operating microscopes for microsurgical procedures. Fournier gangrene is usually managed by the urologists in most centers in collaboration with the plastic surgeons for reconstruction of more extensive defects. Objective: The aim of the study was to review the penile and reconstructive options deployed for post-Fournier gangrene patients over a 3-year period (April 2017 to March 2020) in a tertiary hospital setting highlighting options utilized, indications for the respective options, and challenges encountered. Methodology: Case notes of Fournier gangrene patients offered penoscrotal reconstruction by the urology and plastic surgical teams within the period were retrieved, reviewed, and relevant data useful in achieving the above objectives extracted for analysis. Clinical photographs of some of the patients were included for illustration. Results: Twenty patients (20) that met the inclusion criteria were reviewed. Fourteen (70%) had defects involving both the scrotum and the penis, five (25%) involved the scrotum alone, while one (5%) had defect on the penis alone. Four (20%) had diabetes mellitus, three (15%) had HIV infection, and two (10%) had hypertension. Seventy percent (14) of the patients had secondary wound repair by direct closure, 5% (one) had split skin grafting alone, 5% (one) had a combination of split skin grafting and local advancement flap, and 20% (four) required the use of available locoregional flap [three being bilateral scrotal advancement flaps and one being bilateral pudendal thigh (Singapore) flap]. Healing was satisfactory in all the patients although two of them (10%) had surgical site infection whereas one (5%) had mild wound dehiscence, but all healed within 2 weeks. Conclusion: Post-Fournier gangrene defects can be reconstructed using several options, the choice of which is dependent on the size of the defect, elasticity of residual scrotal skin, status of defined locoregional pedicles, availability of modern diagnostic and operating equipment, and expertise of the surgeon. Collaboration between the urologists and the plastic surgeons is recommended for optimal outcome.
Keywords: Fournier’s gangrene, reconstruction, scrotum, Singapore flap
|How to cite this article:|
Ilokanuno CN, Chukwuanukwu TO, Nwankwo EU, Oranusi CK. Penile and scrotal defects post-Fournier gangrene: reconstructive options and challenges in resource limited settings. Nigerian J Plast Surg 2020;16:65-71
|How to cite this URL:|
Ilokanuno CN, Chukwuanukwu TO, Nwankwo EU, Oranusi CK. Penile and scrotal defects post-Fournier gangrene: reconstructive options and challenges in resource limited settings. Nigerian J Plast Surg [serial online] 2020 [cited 2021 Jan 27];16:65-71. Available from: https://www.njps.org/text.asp?2020/16/2/65/303833
| Introduction|| |
Fournier gangrene, first described by Jean Alfred Fournier in 1883, is usually a consequence of a polymicrobial infection with Escherichia More Details coli (aerobic), bacteroides (anaerobic), and streptococci (aerobic and anaerobic)., Initial management usually involves a thorough debridement, often leading to defects that result in shameful exposure of the testes. This can be a source of morbidity and of great psychological concern to the affected patients.
In most instances, the urologists and general surgeons often manage these patients, offering them wound debridement and direct closure,,, but refer to the plastic surgical team whenever the defect appears extensive from their assessment. Even as grotesque as many of them may appear, direct closure is possible in many instances with up to 50% loss of scrotal wall as the latter is highly forgiving. However, in more extensive losses (near total or total losses), reconstruction of a new scrotal sac can be quite challenging. Flaps become inevitable to provide a suitable house for the testes, but blood supply to the flaps can be a problem sometimes as the supplying vessels may have been compromised by the infective process. Several options are available, including pudendal thigh flaps, also known as Singapore flap, and they have been found useful in such instances. For the flaps to survive, the viability of the supplying vessels needs to be ascertained and where the local tissues have been compromised by the infective process, distant flaps and free tissue flaps may be indicated. In these instances, modern diagnostic, investigative, and surgical instruments will be required. In resource limited settings like ours, these are not readily available and affordable, thereby limiting our options for care.
| Objective|| |
The objective of the study was to review the penile and reconstructive options deployed for post-Fournier gangrene patients over a 3-year period (April 2017 to March 2020) in Nnamdi Azikiwe University and Nnamdi Azikiwe University Teaching Hospital, Nnewi (NAUTH) Nnewi highlighting options utilized, indications for the respective options, challenges encountered, and recommendations for optimal outcome.
| Patients and methods|| |
This is a retrospective study of all the post-Fournier gangrene defects that presented through the surgical outpatient clinics and Accident and Emergency of the hospital over the last 3 years (April 2017 to March 2020).
Case notes of patients were retrieved, reviewed, and relevant data useful in achieving the above objectives extracted for analysis. Twenty patients who had complete data were analyzed and presented [Table 1]. Clinical photographs of some of the patients were also included for illustration.
For the patient that required Singapore flap after full clinical assessment and workup [Figure 4]a, the flap markings were done after using handheld Doppler to identify the supplying arteries [Figure 4]b, the surgical sites were prepared and draped, the flaps were raised bilaterally [Figure 5], and used to construct the neo scrotum without tension [Figure 6]. The healing was satisfactory [Figure 7] and patient was discharged on the fourteenth day postoperatively.
Patient under spinal anaesthesia, positioned supine with both thighs abducted and externally rotated. Routine cleaning and draping were done. Handheld Doppler was used to identify the vessel’s territory (often found in the vicinity of the ischial tuberosity). Flap marking was done while planning in reverse (inverted U shaped with base distally). Proximal margin of the flap was incised and flap elevated as fasciocutaneous flap with incisions taken down to deep fascia on both sides (medial groin crease and laterally).
Size of flap was adjusted to size of defect. Transposition of the flap was done bilaterally to cover the defect. Fascia to skin closure was done for donor site. Appropriate wound dressings were applied exposing areas for flap inspection. The flaps were monitored closely for evidence of impaired blood supply by observing the exposed parts for color changes. Patient was continued on antibiotics for 1 week. Drains inserted were removed after 5 days and patient was continued on analgesics and hematinics and wound care for 14 days.
| Results|| |
The demographic data of the 20 patients including age, part of genitalia involved, option of repair, size of defect, associated comorbidities, and complications are summarized in [Table 1]. The age range of the patients was from 35 to 76 years with a mean of 52 years.
Fourteen (70%) had defects involving both the scrotum and the penis, five (25%) involved the scrotum alone, while one (5%) had defect on the penis alone. In terms of comorbidities, four (20%) had diabetes mellitus, three (15%) had HIV infection, and two (10%) had hypertension. For management, 70% (14) of the patients had secondary wound repair by direct closure, 5% (one) had split skin grafting alone, 5% (one) had a combination of split skin grafting and local advancement flap, and 20% (four) required the use of available locoregional flap − three being bilateral scrotal advancement flaps [Figure 1],[Figure 2],[Figure 3] and one being bilateral pudendal thigh (Singapore) flap [Figure 4],[Figure 5],[Figure 6],[Figure 7]. Healing was satisfactory in all the patients although two of them (10%) had surgical site infection, whereas one (5%) had mild wound dehiscence, but all healed within 2 weeks.
Minimum follow-up period was 1 month.
| Discussion|| |
Penile and scrotal reconstruction of post-Fournier gangrene defects remains a big challenge as one targets to achieve the principle of replacing like with like to ensure continued functional performance during intercourse as well as the testicular temperature regulatory function of the scrotal sac. In view of this, it is generally accepted that native scrotal skin remains the best option where possible.
Options available in literature include healing by secondary intention, direct closure, skin grafting, and use of locoregional flaps, the choice of which is dependent on the size of the defect and expertise of the operating surgeon. Defects that are small in size and generally less than 50% of the scrotum are usually closed directly and much smaller ones even allowed to heal by secondary intention.,, It is therefore not surprising that majority of the patients in this review had secondary direct closure.
Larger defects (>50%) are indications for use of skin grafts or flaps,, skin being thin like scrotal skin is good as it keeps the testes cool. Skin graft take is usually satisfactory in the presence of healthy granulation tissues and intact tunica vaginalis and is particularly useful in resurfacing the penile shaft. It is however known to be more vulnerable to trauma than flaps.
Cases with more extensive, near total, or total loss of scrotum and those where the testes have lost tunica vaginalis are good indications for use of flaps. Many flaps have been described by different authors, namely, pudendal thigh flap,, anterolateral thigh fasciocutaneous flap, gracilis flap, medial thigh flap, vertical rectus abdominis flap, each with its merits and demerits. The use of any of these flaps is predicated upon a confirmed patency of the blood supply or its non involvement by the disease process involved in Fournier gangrene.
Singapore flaps are locoregional flaps in relation to the scrotum and bears similarities with it in terms of color match and sensation. Therefore, its choice obeys the law of replacing like with like. This informed our choice. First described by Wee and Joseph from Singapore and later modified by Woods et al. team, it is based on the posterior scrotal artery from internal pudendal artery and innervated by the pudendal nerve and cutaneous branches from the posterior cutaneous nerve of the thigh. It is also used in reconstructing vaginal defects or in creating a neo-vagina in cases of agenesis.
Many surgeons have adopted it as an excellent choice for reconstructing major scrotal defects with a very high flap survival rate. Unilateral or bilateral flaps can be utilized depending on the size of the defect. Bilateral flaps were used in the patients reviewed [Figure 4],[Figure 5],[Figure 6],[Figure 7] and the perforators of the flaps were confirmed using a handheld Doppler. This confirmation is highly advisable in postinfective cases like Fournier gangrene, where there is a possibility of thrombosis of the supplying vessels. The flap, an inverted U, can be up to 6 to 8 cm wide by 15 cm long depending on the laxity in each patient and the tissue requirements. This ensures that the donor site most times is closed directly as used in our patient.
Amita and Madhav in their series, which were similarly followed up to 1 month postoperatively, noted that all patients presented with stable, viable flaps. Furthermore, all flaps had exceptional color matches to the surrounding tissue in addition to excellent pain and light touch sensation. All of them reported high levels of satisfaction with respect to the aesthetic appearance as well as the functionality and sensation of their new scrotal sacs as seen in our patients.
Muscle and myocutaneous flaps such as gracilis, rectus abdominis, split gluteus maximus flaps are also options useful in large skin defects with deep pockets or cavities to eliminate the dead space, but are not without their drawbacks.Challenges faced included late presentation of some of the patients to the tertiary health care facility where the appropriate personnel are available, late invitation of the plastic surgeons to comanage, a limited number of plastic surgeons (only two compared to eight urologists and six general surgeons), unavailability of handheld Doppler (we had to source for the handheld Doppler used here on our own), unavailability of microsurgery operating microscope and instruments (we had to use our personal operating loupe), and poverty on the part of the patients (many were unable to buy the needed high-cost antibiotics in the postop period. This may have contributed to the wound infections in a few patients.
An algorithm [Figure 8] for successful scrotal reconstruction has been proposed and is largely based on the size of the scrotal defect. Complete coverage of one testis with exposure of the other testis was sufficient to permit primary closure of both testes. However, partial coverage of one testis with exposure of the other testis was an indication for unilateral pudendal thigh flap. Bilateral pudendal thigh flaps were used when both testes were exposed.
| Conclusion|| |
The penile and scrotal reconstructive options deployed in the management of post-Fournier gangrene defects are many and the choice is individualized depending on the characteristics of the defect, surgeon’s expertise, and availability of devices for any given option. More complex defects are successfully managed in centers where collaboration with plastic and reconstructive surgeon is possible.
Collaboration between the plastic surgeons with the urologists and general surgeons in the management of large perineal defects is recommended for optimal outcomes. There should be early involvement of the plastic surgeons in such cases and training of more plastic and reconstructive surgeons to serve the teaming population requiring their services. The hospitals should procure the needed instruments and equipment for microsurgery and sponsor the plastic surgeons for further trainings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pernetti R, Palmieri F, Sagrini E, Negri M, Morisi C, Carbone A et al.
Fournier’s gangrene: clinical case and review of the literature. Arch ItalUrol Androl 2016;88:237-8.
Ekelinus L, Björkman H, Kalin M, Fohlman J. Fournier’s gangrene after genital piercing. Scand J Infect Dis 2004;36:610-2.
Carvalho JP, Hazan A, Cavalcanti AG, Favorito LA. Relation between the area affected by Fournier’s gangrene and the type of reconstructive surgery used. A study with 80 patients. Int Braz J Urol 2007;33:510-4.
Akilov O, Pompeo A, Sehrt D, Bowlin P, Molina WR, Kim FJ. Early scrotal approximation after hemiscrotectomy in patients with Fournier’s gangrene prevents scrotal reconstruction with skin graft. Can Urol Assoc J 2013;7:E481-5.
Okeke LI. Fournier’s gangrene in Ibadan. Afr J Med Sci 2000;29:323-4.
Tan BK, Rasheed MZ, Wu WT. Scrotal reconstruction by testicular apposition and wrap-around skin grafting. J Plast Reconstr Aesthet Surg 2011;64:944-8.
Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier’s gangrene. Burns 2003;29:857-62.
Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report. Plast Reconstr Surg 1989;83:701-9.
Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg 1992;90:270-4.
Yao H, Zheng D, Wen J, Li J, Lu M, Xu M et al.
Reconstruction of major scrotal defects by anterolateral thigh flap. Cell Biochem Biophys 2014;70:1331-5
McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 1976;58:176-83.
Yang J, Ko S, Oh S, Jung S. Reconstruction of a perineoscrotal defect using bilateral medial thigh fasciocutaneous flaps. Arch Plast Surg 2013;40:72-4.
Kesim SN, Topalan M, Ermis I, Görgün B, Yavaş F. Total scrotal reconstruction with vertical rectus abdominis musculocutaneous (VRAM) flap in the treatment of penoscrotal lymphedema. Eur J Plast Surg 1992;15:247-9.
Salim A, Sequina A, Shiyas M, Ruba S, Rehan Z, Mofeed M et al.
Versatility of Singapore flaps in the reconstruction of scrotal defects. Scientonline.org JGS 2018;2:9.
Amita J, Madhav M. Effectiveness of Singapore flaps for perineal reconstruction of Fournier’s gangrene in a tertiary care hospital. Ind J Sci Res 2019;8:77-8.
Shih-Yi C, Ju-Peng F, Tim-Mo C, Shyi-Gen C. Reconstruction of scrotal and perineal defects in Fournier’s gangrene. J Plast Reconstruct Aesthet Surg 2011;64:528-34.
Pawan A. Scrotal reconstruction: our experience. J Surg Pak Int 2012;17:32-4
El-Sabbagh AH. Coverage of the scrotum after Fournier’s gangrene. GMS Interdiscip Plast Reconstr Surg DGPW 2018;7:Doc01. doi: 10.3205/iprs000121. eCollection 2018.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]