Fournier's Gangrene: Overview of Prognostic Factors and Definition of New Prognostic Parameter

doi:10.1016/j.urology.2009.08.090

Urology

Volume 75, Issue 5, May 2010, Pages 1193-1198

https://doi.org/10.1016/j.urology.2009.08.090 Get rights and content

Objectives

To identify the prognostic factors and the new parameters that might predict a worse outcome in nonsurvivors compared with survivors of Fournier's gangrene (FG) and evaluated the validity of the Fournier's Gangrene Severity Index (FGSI) in patients with FG.

Methods

The medical records of 18 patients with FG who were treated and followed up in our clinic were reviewed. Data were collected in terms of medical history, symptoms, and physical examination findings. The biochemical, hematologic, and bacteriologic study (aerobic and anaeorobic wound cultures) results at admission and at the final evaluation, the physical examination findings, the timing and extent of surgical debridement, and the antibiotic therapy were also recorded. The Charlson Comorbidity Index (CCI) and FGSI were evaluated stratified by survival.

Results

The results were evaluated for 2 groups: those who survived (n = 14) and those who did not (n = 4). The admission FGSI score was 5.00 ± 2.91 (range 0-10) for survivors compared with 13.5 ± 2.62 (range 9-15) for nonsurvivors (P = .001). The CCI score was 3 ± 1.5 in survivors and 7 ± 2.2 in nonsurvivors (P = .008). Individual laboratory parameters such as hypomagnesemia, hemoglobin, hematocrit, alkaline phosphatase, creatinine, and the heart and respiratory rates were associated with a worse prognosis. In addition, a FGSI >9, rectal involvement, colostomy diversion, and a high CCI were associated with high mortality.

Conclusions

Low magnesium levels might be a new parameter for a worse prognosis. High CCI and FGSI scores might be associated with a worse prognosis in patients with FG. A FGSI threshold of 9 was a predictor of mortality during the initial assessment.

Section snippets

Material and Methods

The medical records of 18 patients with FG who were treated and followed up from December 2006 to December 2008 in our clinic were reviewed. Data were collected in terms of medical history, symptoms, and physical examination findings. The biochemical, hematologic, and bacteriologic study (aerobic and anaeorobic wound cultures) results at admission and at the final evaluation, the physical examination findings, the timing and extent of surgical debridement, and the antibiotic therapy were also

Results

Of the 18 patients evaluated, 4 (22.2%) died and 14 (77.8%) survived. The overall median age was 57.0 years. The median admission time was 4 days and was similar between the survivors and nonsurvivors.

The patients were evaluated by the onset of symptoms. The first symptom had appeared in the scrotum in 12 survivors and 3 nonsurvivors, and it had appeared in the perineum in 2 survivors and 1 nonsurvivor. The median extent of the body surface area (TBSA%) involved in the necrotizing process in

Comment

In the present study, we demonstrated that a greater CCI and FGSI (>9), low magnesium levels, and other laboratory parameters, including hematocrit, hemoglobin, creatinine, ALP, might be prognostic factors and related mortality in patients with FG.

FG is a synergistic necrotizing fasciitis of the perineal, genital, and perianal region that leads to thrombosis of the small subcutaneous vessels and results in the development of gangrene of the overlying skin. It is an acute urologic emergency,

Conclusion

FG is an uncommon necrotizing fasciitis of the genitalia and perineum and has high mortality and morbidity. Hematocrit, hemoglobin, creatinine, ALP, TBSA%, heart and respiratory rates, rectal involvement, and diverting colostomy were associated with a worse prognosis. Low magnesium levels might be used as a new parameter indicating a worse prognosis. A high CCI and FGSI might be associated with a worse prognosis in patients with FG. A FGSI threshold of 9 was a predictor of mortality during the

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Cited by (68)

Favorable Safety Outcomes of Delayed Primary Closure of Large Fournier's Gangrene Skin Defects
2023, Urology
To assess the feasibility and safety of delayed primary closure (DPC) in Fournier’s gangrene (FG) patients with large genital defects.
A single institution retrospective review was performed from October 2020 to December 2022 of adult males that underwent DPC for FG. All patients underwent standard medical management and were assessed for DPC eligibility by the urology service. Clinical data on patient factors and outcomes were collected, and descriptive statistics were assessed.
Of 16 patients that underwent DPC, the average age was 61.1 years and body mass index was 34.6 kg/m². Median Charlson Comorbidity Index was 3.5 (IQR 2-5.3) and Fournier’s Gangrene Severity Index was 6.5 (IQR 4.8-8). Median number of debridements was 2.5 (IQR 2-3), with a time to closure of 6.5 days (IQR 3-11) and length of stay of 13 days (IQR 9-16.3). Mean genital defect size was 119 cm² (range 44-346 cm²). Eight patients (50%) were closed using scrotal flaps alone while other patients had advancement flaps using the inner thigh, lower abdomen, and perineum. The majority of patients were discharged home directly (63%). There were four Clavien-Dindo III complications: two partial flap necrosis, one wound dehiscence, and one instance of bleeding. Of patients with follow-up, 6/15 (40.0%) had no known complications.
DPC is safe and effective for a range of patients presenting with FG. Patients with large defects may benefit from less complex wound management and direct discharge home.
The role of quick Sepsis-related Organ Failure Assessment score as simple scoring system to predict Fournier gangrene mortality and the correlation with Fournier's Gangrene Severity Index: Analysis of 69 patients
2023, Asian Journal of Urology
Fournier's gangrene is a rare but life-threatening infection disease with high mortality rate. The quick Sepsis-related Organ Failure Assessment (qSOFA) is a new and simpler scoring system that may identify patients with suspected infection who are at greater risk for a poor outcome. The purpose of this study was to find out role of qSOFA in determining prognosis of Fournier's gangrene patients.
This study is a case control with retrospective review of Fournier's gangrene patients treated at Hasan Sadikin Hospital from January 2013 to December 2017 who met inclusion criteria. Participants were divided into two groups according to qSOFA score as high qSOFA (2–3) and low qSOFA (0–1).
From 69 patients, the mortality rate was 24.6%. The sensitivity of qSOFA score to predict mortality was 88.2%; the specificity was 94.2%; positive predictive value was 83.3%; negative predictive value was 96.1%; positive likelihood ratio was 15.2; negative likelihood ratio was 0.12; and the area under the receiver operating characteristic curve of qSOFA was 94.2%. There was significant association between qSOFA scale and mortality with p-value of 0.0001. The qSOFA score has strong positive correlation with Fournier's Gangrene Severity Index (p<0.0001, r=0.704).
qSOFA scoring system has a high prognostic value and can be used to determine prognosis of Fournier's gangrene patients.
The Role of the Platelet Mass Index (PMI) as a New Prognostic Factor in Fournier's Gangrene
2018, African Journal of Urology
Citation Excerpt :
In many studies, an increased ALP level has been identified as an indicator of poor prognosis; however, we found no difference between survivors and non-survivors. Magnesium (Mg) is an important intracellular cation, and its loss in the urine, impaired intestinal absorption, or intercellular shifts are mechanisms that cause low Mg levels [5]. Mg is an important regulator of cardiac contractility and also plays a role in wound healing [13].
Fournier’s Gangrene is a mortal disease. Monitoring of the prognosis of patients is of utmost importance while planning the treatment strategies.
To evaluate the platelet mass index (PMI) calculated by multiplying the platelet count by the mean platelet volume, the Uludag Fournier’s Gangrene Severity Index (UFGSI) and some biochemical markers including Mg, for predicting mortality in a single-center patient population with Fournier’s Gangrene (FG).
The medical records were reviewed for 46 patients with FG who were treated and followed up in a tertiary care center between May 2005 and November 2017 . The medical history of the patients, physical examination findings, biochemical and hematological data, and bacteriological results were recorded. Antibiotic therapy and the extent of debridement were also recorded. The PMI level, Mg level, and UFGSI score were evaluated and stratified by survival.
The results were evaluated for the survivor (n = 33) and non-survivor (n = 13) patients. The first symptom had appeared in the scrotum in 20 survivors and 10 non-survivors, in the perineum in 10 survivors and 2 non-survivors, in the penis in 1 survivor and in 2 nonsurvivors, and in the inguinal region in 3 survivors. The mean admission time was 7.12 days for survivors and 6.77 days for nonsurvivors. The mean wound surface area involved in the necrotizing process was 2.05% in survivors and 3.12% in non-survivors (P = 0.087).The PMI levels at admission were 2283.52 ± 856.84 and 2085.73 ± 1003.40, for the survivors and nonsurvivors, respectively (P = 0.505), whereas the final PMI levels were 2930.08 ± 877.01 and 1473.15 ± 937.74, respectively (P < 0.001). The admission UFGSI and ACCI scores were significantly higher in non-survivors (P = 0.002, P = 0.002, respectively). Hypomagnesemia, low albumin, high heart and respiratory rates, UFGSI > 9, and high ACCI were associated with worse prognosis. Categorical variables were compared using Pearson’s Chi-square test. White independent samplet test or Mann–Whitney U test were used to compare continuous variables. Receiver operating characteristics (ROC) analysis revealed that the final PMI level was more powerful than the UFGSI and Mg level.
Low PMI levels might be an important parameter for a worse FG prognosis. Monitoring the PMI levels might therefore have prognostic and therapeutic implications, as high UFGSI scores and low Mg levels could be associated with a worse prognosis in patients with FG.
Surviving Fournier's gangrene: Multivariable analysis and a novel scoring system to predict length of stay
2018, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Many patients still face the risk of mortality, confirmed by our rate of 5%, though these risks are relatively improved compared to several decades ago.3,14 Several studies have attempted to compare scoring systems in order to validate them, and many have proposed novel scoring systems to predict mortality and disease severity.7,8,10,16–21 Still, no scoring system has been developed to predict length of stay, and as the disease paradigm shifts towards increased survival, practitioners must consider reconstruction and quality of life outcomes.
There is no contemporary scoring system to predict hospital length of stay and morbidity in Fournier's gangrene. A retrospective study was conducted to formulate a scoring system to predict duration of hospitalization, resource utilization, need for reconstruction, morbidity and mortality.
A retrospective chart review was performed on 54 patients treated for FG from 2010–2016 at LAC+USC Medical Center, the largest public hospital in Los Angeles County. Strobe guidelines were followed and the study was approved by the IRB. Predictors of LOS, morbidity, mortality and resource utilization were identified and univariate linear regressions performed to determine significance. Significant univariate predictors were used to develop a novel scoring system, the Combined Urology and Plastics Index (CUPI). The CUPI score was then compared to existing scoring systems for predicting length of stay.
The mean patient age was 49.3, and the mean BMI was 28.6. Patients on average were hospitalized for 37.5 days, with a mean of 8.3 days in the ICU. Three patients (5.6%) died during their hospital stay, and 33 (61%) required reconstructive surgery. Multivariate logistic modeling showed that BMI (p = 0.001) and alkaline phosphatase (p < 0.001) correlated with decreasing length of stay, while age at admission was not significantly correlated (p = 0.369). Univariate analysis of existing scoring systems showed that FGSI, LRINEC, NLR, and CCI were not significantly correlated with length of stay, while the newly calculated CUPI score was shown to be a significant predictor of longer hospital stays (p = 0.001).
Early emphasis on supportive care, nutrition, and involvement of reconstructive surgeons can decrease LOS in patients with Fournier's gangrene. The CUPI score on admission may be a useful tool for predicting LOS in this population.
Temperature-Neutrophils-Multiple Organ Failure Grading as a Prognostic Indicator in Fournier Gangrene
2023, Surgical Infections
Can HALP score, a new prognostic tool, take the place of traditional scoring systems in Fournier’s gangrene?
2023, International Urology and Nephrology

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Reconstructive UrologyFournier's Gangrene: Overview of Prognostic Factors and Definition of New Prognostic Parameter

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusion

J Urol.

J Chronic Dis.

Eur Urol.

J Urol.

J Urol.

Fournier's gangrene: report of 20 patients

J Urol.

Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia

Surg Gynecol Obstet.

Synergistic gangrene of the scrotum and penis secondary to colorectal disease

J Urol.

Fournier's gangrene: experience with 25 patients and use of Fournier's Gangrene Severity Index score

Urology

Is Fournier's Gangrene Severity Index useful for predicting outcome of Fournier's gangrene?

Urol Int.

Gangrene and Fournier's gangrene

Urol Clin North Am.

Fournier's syndrome of urogenital and anorectal origin: a retrospective and comparative study

Dis Colon Rectum.

Reconstructive Urology
Fournier's Gangrene: Overview of Prognostic Factors and Definition of New Prognostic Parameter