Fournier’s gangrene is a serious and morbid necrotizing infection of the perineal, scrotal, and genital soft tissues.¹ Thrombosis and necrosis of the vascular supply to affected tissues underlie the pathophysiology of Fournier’s. As such, tissues supplied by branches of the inferior epigastric and circumflex iliac arteries that travel within Colles’ fascia are most affected, including the anterior scrotum, perineum, and inguinal regions. Tissues with an alternate blood supply, such as the testicles (gonadal) and posterior scrotum (internal pudendal), and medial thigh (medial circumflex femoral) are often spared.

Patient-specific factors predisposing individuals to Fournier’s continue to rise in prevalence, including advancing age, vascular, diabetes, and obesity.² Despite this, contemporary data suggest early recognition and prompt, aggressive surgical management of Fournier’s gangrene have been effective at decreasing acute mortality from the disease.³ These factors have led to a growing population of frail patients requiring extensive genital reconstruction after initial debridement and recovery. As such, we prefer reconstructive approaches that prioritize simplicity and the incorporation of healthy, well-vascularized tissues to minimize the risk of postoperative complications and their associated morbidity.

Many scrotal and perineal reconstruction options have been described in the literature, including primary closure, component separation closure, scrotoplasty with local flaps, split-thickness skin grafting, and construction of testicular thigh pouches.^4,5 The literature regarding surgical outcomes following reconstruction is generally limited to smaller retrospective studies.^6-8 Unfortunately, there have been no large-scale prospective comparative studies assessing surgical outcomes and patient satisfaction following these reconstructive approaches. We also have limited data regarding patient priorities at the time of Fournier’s reconstruction and how their priorities factor into their decision-making process. While the health of local tissues and the extent of initial debridement should guide approach selection, we argue that a low threshold to reconstruct with permanent thigh pouches is often in the patient’s best interest. It is also important to note that the use of thigh pouches at the time of initial closure does not preclude future revision with formal scrotoplasty in a delayed fashion if patients report dissatisfaction with the final cosmesis or discomfort.

In the setting of minimal perineal debridement, we typically create medial thigh pouches using blunt dissection superficial to the fascia lata bilaterally with primary closure of these mobilized flaps at the midline of the perineum to the base of the penis.⁹ This can be done with or without concurrent grafting of the penile shaft. If larger tissue defects preclude primary closure, local flaps may be mobilized to provide additional coverage using a discrete vascular pedicle. If suprapubic debridement leaves a large defect overlying the mons pubis, an inferior abdominal advancement flap can be mobilized. If additional coverage is needed to minimize tension on the perineal closure of the suprapubic region lateral to the penis, a fasciocutaneous flap can be mobilized from the lateral thigh and placed over the testicle and other defect (Figure 1). This may be particularly beneficial for frail patients who may not have the reserve or physiology to support skin graft healing. These approaches also minimize the need for postoperative dressing changes and/or vacuum-assisted closure devices, thus simplifying the postoperative care regimen and possibly expediting discharge.

The use of split-thickness skin grafting is commonly touted as an optimal approach for reconstruction given the degree to which the final appearance most closely recapitulates standard male genitourinary anatomy.¹⁰ However, the factors required for graft take, including robust underlying vascularity and immune support, are often compromised in patients requiring Fournier’s reconstruction. This can lead to significant graft complications, including graft loss (Figure 2) and prolonged hospitalization relative to simplified reconstructive approaches. Further, even under ideal circumstances, the final cosmesis of split-thickness scrotal skin grafting is limited by the direct adherence of the skin graft to the tunica albuginea of the testicle which may also cause patient discomfort.

In conclusion, we believe that the medical complexity of frail patients undergoing Fournier’s debridement supports reconstructive approaches that minimize complexity and maximize the use of healthy adjacent tissue. This often manifests as primary closure with the creation of lateral thigh pouches but can also include mobilization of medial fasciocutaneous flaps to increase coverage. If patients desire further procedures to better recapitulate native scrotal anatomy, delayed scrotoplasty remains an option (Figure 3). To best counsel patients in these increasingly common scenarios, the urologic community must collaborate to better understand patients’ preoperative reconstruction priorities and better quantify postoperative surgical outcomes and satisfaction.