Attention: Restrictions on use of AUA, AUAER, and UCF content in third party applications, including artificial intelligence technologies, such as large language models and generative AI.
You are prohibited from using or uploading content you accessed through this website into external applications, bots, software, or websites, including those using artificial intelligence technologies and infrastructure, including deep learning, machine learning and large language models and generative AI.
Fournier’s Gangrene Reconstruction: Orchidopexy and Split-Thickness Skin Graft for Scrotal Defects
By: Rebecca Heidenberg, MD, University of North Carolina, Chapel Hill; Eric Walton, MD, University of North Carolina, Chapel Hill; Bradley D. Figler, MD, University of North Carolina, Chapel Hill | Posted on: 30 Dec 2024
Necrotizing fasciitis of the genitals, also referred to as Fournier’s gangrene (FG), is a rapidly progressive infection that affects the deep and superficial tissues of the perineum, scrotum, perianal, and genital regions. While FG is rare (~0.0016% of the population in the US), reported mortality is as high as 20% to 40% secondary to septic shock and multiorgan failure.1 Common physical exam findings include scrotal swelling, purulent drainage, and crepitus. CT can be useful for confirming the presence of subcutaneous emphysema, as well as the location of abscesses. Initial treatment involves emergent surgical debridement of necrotic tissue and broad-spectrum antibiotics. Because of its rapidly progressing nature, patients typically return to the operating room 24 to 48 hours after initial debridement to confirm disease control.
Following debridement, genital skin and fascia deficiencies can significantly prolong convalescence due to the need for frequent dressing changes, which may be painful and difficult for the patient themself. Furthermore, many risk factors for FG (eg, diabetes, immunosuppression, malnutrition, obesity, renal failure) contribute to poor wound healing. Therefore, aggressively managing the wound after debridement is essential to a successful recovery.
While small scrotal defects can be closed primarily, defects greater than 50% to 60% of scrotal skin cannot. In this case, reconstruction options include coverage with skin grafts, thigh flaps, and primary closure following use of tissue expanders or testicular transposition to the medial thigh (ie, thigh pouches). We advocate scrotal reconstruction with skin grafts due to the ease and reliability of surgery, and to avoid complications in regions not previously affected by the FG.
While it is possible to utilize Dartos fascia as a graft bed, we prefer to graft directly to tunica vaginalis. In our experience, tunica vaginalis is a more reliable graft bed, and grafting to tunica vaginalis preserves the remaining scrotal skin and Dartos fascia for reconstruction of adjacent (eg, perineal) defects. Since tunica vaginalis is rarely involved in FG, reconstruction can begin as early as 24 hours after initial debridement.
We begin by mobilizing the testicles and spermatic cords to the external ring. A neo-scrotum is created by securing the medial tunica vaginalis of each testicle together with several rows of interrupted absorbable suture. The neo-scrotum is then advanced cephalad and secured to base of the penis with absorbable suture. For longer spermatic cords, this step can significantly decrease the size of the scrotal contents, minimizing the amount of skin needed for grafting and reducing donor site morbidity. While skin grafting can be performed at this time, in patients with FG, we typically wait approximately 1 week to allow resolution of infection, medical optimization, and formation of granulation tissue. Wound care during this time consists of moistened cotton gauze applied twice daily.
At the time of a skin grafting, the neo-scrotum is first gently debrided and irrigated with antiseptic solution. A split-thickness skin graft (STSG) is harvested from the lateral thigh with an air dermatome at a depth of 0.018 inches and meshed 2:1. The donor site is covered with Xeroform (bismuth tribromophenate gauze dressing), which falls off when a scab forms approximately 3 weeks postoperatively. The meshed STSG is secured to the neo-scrotum with chromic suture and fibrin glue. Immobilization of the skin graft, which is essential for optimal graft take, is accomplished with a dressing of Xeroform and mineral oil–soaked cotton gauze that is sutured to the scrotum. The dressing is removed in 1 week, at which point wound care consists of Xeroform gauze application twice daily for 2 weeks. The Figure shows a patient with a scrotal defect after FG and at various stages of reconstruction. Video of this technique has been previously published.2
Orchidopexy and STSG is an excellent option for surgical management of large scrotal defects following FG debridement due to its simplicity, versatility, and aesthetic outcomes.3 Reconstructive urologists and plastic surgeons are familiar with harvesting skin grafts for other indications, and an STSG can be readily applied in this setting without technical modification. In fact, unless the patient has ongoing medical problems, they can discharge home following this procedure without the need for any second stage procedures. Once healed, STSGs have the natural color, shape, and thickness of genital tissue. Meshing the STSG in a 2:1 ratio minimizes donor site morbidity and results in a stippled appearance that resembles scrotal rugae. Once healed, genitals have a normal anatomic configuration.
Unlike flap-based options for post-FG reconstruction, there are few wound healing complications (eg, infection, wound dehiscence) after reconstruction with orchidopexy and STSG. In a systematic review, 96 patients underwent STSG and only 5% experienced wound-healing complications.4 Skin graft contracture and loss are potential complications that occur uncommonly. Chen et al5 reported 11% partial graft loss, which can be managed with local wound care. Similarly, Tan et al6 found 100% graft take in 23 of 24 skin grafts, with 1 patient experiencing infection and scarring.
Proponents of thigh pouches advocate that they protect testes and reduce the size of genital wounds.7 Notably, some patients who receive thigh pouches require skin grafts for reconstruction of their post-FG debridement wounds. Unlike STSG, thigh pouches do not have a natural appearance and have been rated poorly from an aesthetic perspective by patients.4 Any attempt to correct this requires additional surgical intervention to translocate the testes and reconstruct the scrotum. Furthermore, thigh pouches come with the risk of pain and altered physiologic function from being in a nonanatomic location.
In conclusion, orchidopexy and STSG is an excellent reconstructive option for patients with scrotal deficiency secondary to FG. This is a versatile technique that permits coverage of large defects, maintains native genital configuration, and is associated with a low rate of postoperative complications. Therefore, we believe that orchidopexy and STSG should be the reconstructive technique of choice for large scrotal defects after FG debridement.
- Insua-Pereira I, Ferreira PC, Teixeira S, Barreiro D, Silva Á. Fournier’s gangrene: a review of reconstructive options. Cent European J Urol. 2020;73(1):74-79.
- Hayon S, Demzik A, Ehlers M, McGowan M, Mohan C, Figler BD. Orchidopexy and split-thickness skin graft for scrotal defects after necrotizing fasciitis. Urology. 2021;152:196. doi: 10.1016/j.urology.2021.02.007
- Demzik A, Peterson C, Figler BD. Skin grafting for penile skin loss. Plast Aesthet Res. 2020;7:52.
- Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015:15-18.
- Chen SY, Fu JP, Chen TM, Chen SG. Reconstruction of scrotal and perineal defects in Fournier’s gangrene. J Plast Reconstr Aesthet Surg. 2011;64(4):528-534. doi:10.1016/j.bjps.2010.07.018
- Tan BK, Rasheed MZ, Wu WT. Scrotal reconstruction by testicular apposition and wrap-around skin grafting. J Plast Reconstr Aesthet Surg. 2011;64(7):944-948. doi:10.1016/j.bjps.2010.11.013
- Loloi J, Gottlieb J, MacDonald SM, et al. Case - testicular thigh pouches for severe Fournier’s gangrene: a how-to guide. Can Urol Assoc J. 2022;16(10):374-376.
Related Content
advertisement
advertisement