Fournier’s gangrene with prostatic and bladder trigone colliquation: a suggested treatment algorithm
- 1 Unit of Urology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
- 2 Unit of Urology, Department of surgical sciences, University Tor Vergata, Rome, Italy
- Correspondence to Dr Gaia Colalillo; gaia_colalillo@hotmail.it
Abstract
Fournier’s gangrene (FG) is an infectious necrotising fasciitis of the perineum and genital regions with a high mortality rate. We report the case of a man in his 70s with FG who presented with bladder trigone and prostate colliquation. Bulbar and penile urethra were also injured with multiple fenestrations. Bilateral percutaneous nephrostomy positioning followed by the placement of occluding ureteral catheters preceded the surgical debridement of the necrotic tissues and protective colostomy. There followed periodic sessions of surgical debridement and VAC therapy. The persistent perineal urinary leak required the crafting of a suprapubic surgical cystostomy with bladder neck obliteration through double-layer raphy. The cystostomy maintained the healing tissues free from the constant and damaging urine action. This report describes the successful multistep approach of an FG with deep involvement and colliquation of the bladder neck and prostate reaching the Denonvilliers fascia that ensured the correct healing of tissues.
Background
Fournier’s gangrene (FG) is defined as a rapidly progressing infectious necrotising fasciitis of the perineal, perianal and genital regions.1 To our knowledge, no cases of prostate and bladder trigone necrosis secondary to FG have already been reported in the published literature.
The aim of this study is to report our successful treatment algorithm for an FG case with colliquative necrosis of the bulbar and membranous urethra, prostate/bladder neck (BN) and Denonvilliers fascia (DF) associated to superficial involvement of the scrotum, perineum, penile urethra, penile shaft and internal surface of the thighs.
Case presentation
A man in his 70s with body mass index of 24 was referred to the emergency department in critical health conditions, acute cognitive impairment and diarrhoea. Mental confusion, tachycardia (120/min) and tachypnoea were also present while blood pressure was 100/75 mm Hg. Previous radiotherapy for prostate cancer and multiple endoscopic urethrotomies for recurrent urethral strictures were reported.
The physical examination revealed hyperaemia, ecchymosis and bullae of the suprapubic, left inguinal and obturator region and external genitalia associated to fluctuation and crepitus on palpation.
Blood chemistry documented anaemia (7 mg/dL), neutrophil leucocytosis (24 m/L), acute renal failure (serum creatinine: 4.3 mg/dL; blood urea: 65 mg%) and elevation of the serum inflammatory markers (C reactive protein 260 mg/L). Liver function parameters were also altered (serum bilirubin: 3.7 mg%; AST: 77 IU/L; ALT: 64 IU/L), while the electrolytes and the coagulation profile were within the normal range.
The FG Severity Index (FGSI) as suggested by Laor et al 2 was +10, with FGSI >9 being associated to a mortality rate of higher than 75%.3
The patient was transferred to intensive care unit (ICU), and the following supportive therapy was adopted:
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Crystalloids in 3L/24 hours.
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Norepinephrine 0.5 µg/kg/min.
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Broad-spectrum antibiotics (piperacillin/tazobactam 4 g/0.5 g every 6 hours), while attending for the surgical wound swabs and blood and urine-culture reports.
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Parenteral nutrition therapy.
An urgent CT evaluation of the abdomen and pelvis documented severe bilateral hydronephrosis and multiple abscesses with gas formation in the suprapubic, inguinal/left obturator area and at the level of the left corpus cavernosum. The prostate was entirely replaced by multiple centimetric calcifications (figure 1). The previously placed bladder catheter was found displaced in the penile urethra with severe urine leak to the perineum as for incompetence of the BN and prostatic urethra.
Sagittal section of the abdominopelvic CT scan. The prostate is entirely replaced by multiple calcifications. The previously placed bladder catheter is visibly displaced in the bulbar urethra as for incompetence of the bladder neck and prostatic urethra. Bl, bladder; C, catheter; Pr, prostate; Pu, pubis; S, sacrum.
Thus, bilateral percutaneous nephrostomies were placed in emergency, and a few days later, with the patient clinically stabilised, an aggressive surgical debridement of all necrotic tissue with protective colostomy was performed.
The subsequent main surgical steps are summarised below:
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Drainage of the abscess cavities of the suprapubic, left inguinal and obturator region.
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Wide surgical excision of all the necrotic/dystrophic skin and associated subcutaneous tissue of the penis up to the Buck’s fascia; the gangrenous tissue was removed with approximately 1 cm of adjacent healthy tissue margin.
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The gangrenous necrosis involved the corpus spongiosum of the urethra with its tunica albuginea; vast solutions of tissue continuity at the left ventrolateral aspect of the bulbar and penile urethra, showing the underlying urethral catheter were found at surgery (figure 2); a 2 cm stone, impacted in the bulbar urethral segment, was removed.
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The surgical incision was extended to the medial raphe of the perineum and scrotum. The membranous and intraprostatic urethra was necrotic; the whole prostate gland was colliquated and replaced by an abscess containing multiple stones. The surgical debridement of the prostatic cavity documented a yellowish/brownish DF as for gangrenous involvement.
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All visible gangrenous tissue and the multiple stones were removed from the prostatic bed. Multiple swabs were taken from the infected areas for culture. The surgical field was abundantly irrigated with saline and perosside solution. VAC therapy dressing was applied, and a protective colostomy was crafted.
Vast solutions of tissue continuity at the left ventrolateral aspect of the bulbar and penile urethra showing the underlying urethral catheter. The digital exploration inside the bulbar urethra documented the colliquation of the prostate gland. A multitude of centimetric calcifications of the prostate fossa was digitally removed revealing the concomitant colliquation of the bladder neck.
Investigations
Surgical wound swabs documented a meropenem-sensitive Escherichia coli infection. Following a postoperative stay in the ICU, with periodic surgical debridement of the necrotic tissue and changing of the VAC dressing every second day, the patient was transferred to the urology department a week later in improved general conditions.
Treatment
The periodical curettage/surgical debridement of necrotic tissues and associated application of advanced VAC therapy continued for 2 months.
After this period, the patient’s general conditions had markedly improved; however, a constant urine leakage at the level of the perineum persisted. The urine presence hindered the correct healing of the surgical wounds. A bilateral definitive ureterocutaneostomy versus permanent suprapubic surgical cystostomy was therefore taken into consideration.
Following a midline incision, the bladder was isolated with great difficulty due to extensive adhesions. A median longitudinal cystostomy of about 3 cm was performed, and the lumen of the bladder was inspected with the aid of a laparoscope. Although the ureterovesical junction (UVJ) seemed covered by normally appearing mucosa with apparently preserved competence of both the UVJs, the area of the bladder trigone/neck was tapered by a whitish mucosa that proved frail at the digital exploration. The BN was therefore circumferentially incised, and the necrotic tissue was removed; closure/raphy of the BN was performed with a double-layer suture of Monocryl 2–0/3–0 and subsequent application of fibrin glue as a topical biological adhesive. Finally, a suprapubic midline surgical cystostomy was crafted around a 20 Fr silicone Foley catheter, performing a synthesis of the margins of the stoma with the fascia of the rectus muscles.
Outcome and follow-up
The subsequent postoperative course of the patient was uneventful. The perineal urine leak ceased, and the layers of the perineum and external genitalia completely healed.
The clinical and radiological evaluation performed at 12 months following the last surgical procedure revealed a complete healing of the injured areas (figure 3).
At the last visit, a complete healing of the severely injured gangrenous tissues has been obtained.
Figure 4 summarises the described algorithm for the management of similar cases.
Algorithm for approaching of Fournier’s gangrene in patient with prostatic and bladder trigone colliquation. (The figure was made by the author Dr A Asimakopoulos.)
Discussion
In cases of FG with deep involvement of the perineum, VAC therapy,4 faecal5 and urinary diversions (UDs) are of paramount importance to avoid contamination and allow for the healing of tissues.
UD through percutaneous nephrostomy is usually the first step to be adopted. It provides a quick drainage of urine from the pyelocaliceal system; thus, it diverts urine from the injured area.6
However, nephrostomies alone do not provide complete cessation of urine drainage into the urinary bladder. Ureteric peristalsis and low resistances ensure a persistent leakage of urine through the injured tract.6 Thus, ureteral occlusion techniques with appropriate balloon catheters may be used to prevent the antegrade flow of urine. These devices usually ensure a total urine diversion, allowing for the lower urinary tract to remain dry so that fistulous tract healing can occur.7 Despite good overall results, many adjustments and replacements of catheters are necessary because of recurrent urinary leakage caused by inadequate obstruction of the occluding catheters. Moreover, issues about their long-term effects could be raised concerning their local compressive effect and ureteric pressure necrosis. Nevertheless, with these first-line approaches, a surgical UD that is usually necessary may be deferred to the clinical stabilisation and improvement of the patient.
The subsequent choice between a permanent ureterocutaneostomy or cystostomy should be evaluated based on the individual case.
In our case, the careful inspection of the bladder lumen was critical to choose and adopt the better option among the latter options. If the UVJs appear healthy, it seems logical to try to preserve the native bladder and the trigone. This approach allows to avoid a potentially challenging UCS due to:
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The often critical conditions of the patient.
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The possible presence of coexisting colostomy or the scars of a previously performed radiating therapy that usually prevent an easy mobilisation of the ureters. The colostomy in particular makes the left UCS complicated because it obstructs the left iliac fossa. In this occurrence, therefore, a medial-paired UCS or a Y transureteroureterocutaneostomy should be performed, thus increasing the complexity of the procedure and the possibility of postoperative complications.
To our knowledge, no cases of prostate and bladder trigone necrosis secondary to FG have already been reported in the published literature. Gómez Pérez et al 8 have reported a case of partial sloughing of urethra that was re-epithelised from native urethral tissues.
Lee and Hong have reported an unusual presentation of FG involving the bulbous urethra and forming free gas in the urinary bladder which was successfully managed by urgent, aggressive surgical debridement and UD.9 Finally, Paonam and Bag described a case of a patient suffering from prostate cancer with FG and extensive necrosis of the urethra and bladder mucosa. The bladder mucosa was necrotised and friable; after adequate surgical debridement, the bladder was closed on a suprapubic catheter.10
Learning points
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In cases of severe Fournier’s gangrene (FG) with deep involvement of the prostate, bladder neck, urethra and Denonvilliers fascia:
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Stabilise the patient.
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Targeted antibiotic therapy.
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Aggressive surgical removal of the necrotic tissues.
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VAC therapy, faecal and urinary diversion.
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In cases of prolonged perineal leak of urine, perform an intraoperative evaluation of the intactness of the ureterovesical junctions (UVJs); if intact, preserve them and perform a surgical cystostomy around a wide-lumen suprapubic catheter with eventual surgical obliteration of the bladder neck through multilayered raphy (if required). If the UVJs are involved by the FG, consider other forms of urinary diversion such as bilateral ureterocutaneostomy.
Ethics statements
Patient consent for publication
Footnotes
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Contributors GC and AA provided provided substantial contribution to the conception and design of the work as well as analysis and interpretation of data and drafting of the manuscript. GC, AA, SG and RM have revised the work critically for important intellectual content and provided final approval of the version to be published. They agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. SG has been also involved in the patient’s care. All authors contributed to the article and approved the submitted version. AA and SG were the surgeons in charge of the case, and they were involved in management of the patient.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
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