Use of a Vacuum-Assisted Device for Fournier’s Gangrene: A New Paradigm

Case Review

RIU0379_03-14.qxd 3/15/08 3:01 AM Page 76 CASE REVIEW Use of a Vacuum-Assisted Device for Fournier’s Gangrene: A New Paradigm Jonathan Silberstein, MD,* Julia Grabowski, MD,* J. Kellog Parsons, MD, MHS*,†,‡ *Division of Urology, University of California San Diego Medical Center, San Diego, CA; † UCSD Moores Cancer Center, La Jolla, CA; ‡Veterans Affairs Medical Center, San Diego, CA Fournier’s gangrene is a necrotizing infection of the scrotum or perineum that requires aggressive surgical debridement. Radical debridement of perineal necrotizing fasciitis can leave extensive tissue defects that are difficult to close and often require multiple surgical interventions. Vacuum-assisted closure (VAC) devices have been shown to assist in a more rapid closure of these wounds, but placement of such devices in the perineum can pose significant challenges. We have had success with use of VAC devices and report our techniques for their placement. [Rev Urol. 2008;10(1):76-80] © 2008 MedReviews, LLC Key words: Fournier’s gangrene • Vacuum-assisted closure devices ournier’s gangrene (FG) is a progressive subcutaneous infection of the perineum and genitalia. Patients commonly present with pain, erythema, blistering, or foul-smelling necrotic skin lesions. Predisposing factors are thought to include various states of immunosuppression such as diabetes and AIDS. Most cases of FG are caused by polymicrobial flora, which include grampositive, gram-negative, and anaerobic bacteria. These infectious organisms rapidly spread along Colles’ fascia in the perineum and dartos fascia in the scrotum and penis and may even advance along Scarpa’s fascia on the abdominal F 76 VOL. 10 NO. 1 2008 REVIEWS IN UROLOGY RIU0379_03-14.qxd 3/15/08 3:01 AM Page 77 VAC Device for Fournier’s Gangrene wall. FG constitutes one of the few true urologic surgical emergencies with mortality reported to be as high as 16% to 40% even in the modern era.1,2 Treatment requires broad spectrum antibiotics, intravenous fluid resuscitation, and aggressive, extensive surgical debridement. Following radical debridement, closure of the remaining wound can pose significant reconstructive challenges. Wound defects may be allowed to close through secondary intention or with the assistance of various flaps. Allowing these wounds to heal by secondary intention may involve prolonged hospitalizations. Alternatively, tissue flaps require multiple surgical interventions and risk failure. To facilitate closure of these wounds and expedite patient recovery with minimal intervention, we have employed a vacuum-assisted closure (VAC) technique. There is abundant evidence from the general surgery and orthopedic literature supporting the benefits of VAC compared with a paucity of urologic literature on their application, which suggests that this technique may be underutilized by urologists. This is not surprising given that successful placement of VAC devices in the perineum can be technically difficult. The following case is presented to outline some of our strategies of how best to apply VAC devices, followed by a brief review of the literature. Case Presentation and Hospital Course A 47-year-old, otherwise healthy, diabetic man presented to the emergency department with perineal pain and fever (101.8°F) of 8 days duration. Other vital signs were within normal limits. The patient noted that he had malaise, myalgias, and anorexia. Physical examination revealed a pleasant male with an 18  10 cm area of erythema along his gluteal Figure 1. Fournier’s gangrene following radical debridement prior to treatment with wound vacuum-assisted closure (VAC) device. fold. The area was tense, fluctuant, warm, and extended to the scrotum. The patient’s past medical history was significant for diabetes only. He denied a history of HIV, tobacco or alcohol abuse, or hemorrhoids. The patient controlled his blood glucose with oral hypoglycemic agents, and a recent hemoglobin A1c (HbA1c) test was 6.1%. The patient’s white blood cell count was 21.6  10 3 with 83% neutrophils. Serum electrolytes revealed a sodium level of 127 mEq/L, a chloride level of 83 mEq/L, a bicarbonate level of 27 mEq/L, a creatinine level of 1.8 mg/dL, a blood urea nitrogen level of 27 mg/dL, and a glucose level of 593 mg/dL. Intravenous fluids, a continuous insulin infusion, and broad-spectrum antibiotics were initiated in the emergency department, and the patient was taken emergently to the operating room for radical debridement of the area. Necrosis spread across the scrotum and perineum. Purulent fluid tracked into the right buttock, but the anus was spared. The wound was dressed with saline-soaked gauze. Preoperative blood and urine cultures were negative. Wound cultures taken during the operation grew Klebsiella pneumoniae, Enterococcus faecalis, Streptococcus Milleri strains 1 and 2, Bacteriodes uniformis, Provotella disiens, and Peptostreptococcus. Postoperatively the patient’s elevated glucose, creatinine, and acidosis resolved. The patient returned to the operating room 48 hours later for further inspection and debridement (Figure 1). Two days later, there was no further evidence of active infection, the wound was copiously irrigated, and a VAC device was placed (Figure 2). A large sponge was cut into several pieces and stapled into the wound (Figure 3). Prolene sutures (size 1-0) were placed in the most inferior portion of the wound, bringing the skin together and allowing for easier placement of the wound VAC sponge drape (Figure 4). The edges of Figure 2. Wound VAC device in place. VOL. 10 NO. 1 2008 REVIEWS IN UROLOGY 77 RIU0379_03-14.qxd 3/15/08 3:01 AM Page 78 VAC Device for Fournier’s Gangrene continued the wounds were covered with benzoin ointment to help keep the drape in place. The drape was cut into several pieces and placed over the sponge. A small hole was then cut in the drape, the vacuum tubing was placed, and suction was applied. Subsequently, the patient underwent VAC changes every 2 to 3 days (Figure 5). The patient’s antibiotic regimen was tailored to his specific organisms, and he completed a 21-day course of antibiotic therapy. The patient was discharged with a portable VAC device on postoperative day 23 and returned to clinic every 3 days for VAC changes. The VAC was discontinued on postoperative day 38 and healing continued successfully (Figure 6). Soft tissue defects of the perineum result most frequently from gangrenous infections and subsequent wide local debridement. Following removal of infected tissue, wound treatment and closure in this anatomic region can be particularly challenging because of its proximity to the anus and potential for fecal contamination, the rotational forces placed on it with ambulation and movement, and its sensitivity due both to neurologic and psychologic factors. Care of these soft tissue defects frequently requires prolonged hospitalization with wound closure through secondary intention, myocutaneus rotation flaps, free flaps, omental flaps, skin grafts, or some combination of all of these techniques. Most authors recommend treating wounds as a result of necrotizing fasciitis with multiple rounds of debridement and daily dressing changes. Some authors advocate the use of Dakin’s solution, honey,3 or hyperbaric oxygen4 to facilitate closure. Even with these modifications to traditional dressing changes, however, wound closure is often lengthy. Figure 4. Prolene sutures were placed in the most inferior portion of the wound because of the close proximity to the rectum. Figure 5. Wound at the time of a VAC change on postoperative day 12; healthy granulation tissue is present throughout wound. Figure 6. Patient at clinic visit on postoperative day 74. Figure 3. Wound VAC device sponge, cut into several pieces for easier placement into irregularly contoured wound. 78 VOL. 10 NO. 1 2008 Discussion REVIEWS IN UROLOGY RIU0379_03-14.qxd 3/15/08 3:01 AM Page 79 VAC Device for Fournier’s Gangrene There are many studies in the general surgery, orthopedic, and gynecological literature supporting the use of VAC devices. A VAC device consists of a sterile, open-cell foam sponge that is placed in the wound. This is covered with a transparent adhesive drape that creates an airtight environment. Noncollapsible tubing is used to connect this to a portable pump that provides continuous negative pressure. The VAC device is thought to increase wound healing by providing microstrain, which promotes more rapid wound closure by encouraging perfusion, fibroblast migration, and cell mitosis and proliferation; removing infected materials and excess exudates; reducing localized edema; and drawing wound edges together. Randomized prospective control studies have demonstrated improved wound dressing changes either at the treating physician’s office or with a home health nurse. Despite a multitude of potential applications, there are few reports in the genitourinary literature of practitioners utilizing the wound VAC devices. Rosser and colleagues demonstrated more rapid discharge (35 vs 73 days) when a wound VAC device was applied to large soft-tissue defects in the perineum from FG.6 In addition to FG, VAC devices have also been used with great success to secure circumferential split thickness skin grafts to the penis7 and to treat wound failures following inguinal lymphadenectomy for penile carcinoma8 as well as infected penile prosthesis, trauma to the urogenital region, drained abscesses to the scrotum, abdominal wound separations, and bulbar urethral necrosis.9 Traditional wet-to-dry dressing changes require multiple dressing changes in a 24-hour period, which may be painful for the patient and burdensome for the medical staff. Vacuum-assisted closure (VAC) therapy, on the other hand, is reapplied only every 48 to 72 hours. healing and a significant reduction of wound surface area in full-thickness wounds treated with VAC devices as compared with conventional gauze therapy.5 Traditional wet-to-dry dressing changes require multiple dressing changes in a 24-hour period, which may be painful for the patient and burdensome for the medical staff. VAC therapy, on the other hand, is reapplied only every 48 to 72 hours. This reduces the number of dressing changes, increasing patient comfort. Patients may be mobile with the VAC device in place. Some of the portable pumps run on batteries and allow for continuous therapy while the patient is away from an electrical outlet. Patients may be discharged with the VAC device in place and receive While wound VAC devices have been shown to be useful in a variety of situations, one unique potential benefit to their use in the genitourinary region is that the drape may act as an airtight barrier to fecal soilage, preventing contamination in this anatomic region. Interestingly, Moues will need to be completed to elucidate this point. Evidence suggests that vacuumassisted closure devices may be utilized for a variety of genitourinary wounds, but their placement can pose significant challenges. The first step in VAC device placement entails application of a spongy foam material to the wound bed, with placement of an adhesive drape over the sponge. Application of these devices, especially to unusually contoured regions of the body such as the perineum, may prove challenging. Placement of the foam into irregularly shaped regions or tunneled areas of a wound can be overcome by cutting the foam into smaller pieces with shapes that best match the region for desired coverage (Figure 3). Care must be taken to note how many pieces of foam were placed in the wound to ensure removal of all of these pieces at subsequent dressing changes. There is no loss of efficacy with cutting the foam, and often this simply makes it more manageable. Stapling the sponge material in place before applying the draping material may prove useful, as this helps prevent the sponge from falling out of position and facilitates placement of the adhesive drapes. Removing all the staples at dressing changes and making certain not to staple the urethra or testicles and injure underlying structures is imperative. While wound VAC devices have been shown to be useful in a variety of situations, one unique potential benefit to their use in the genitourinary region is that the drape may act as an airtight barrier to fecal soilage. and coworkers’ prospective, randomized control study5 did not demonstrate a decrease in wound bacterial colonization with use of the VAC device. However, this study did not look at perineal wounds. Further studies Cutting the adhesive draping material often makes it more manageable and easier to apply. Overlapping the draping material and ensuring coverage of the sponge plus at least 3 mm of normal skin wherever possible will VOL. 10 NO. 1 2008 REVIEWS IN UROLOGY 79 RIU0379_03-14.qxd 3/15/08 3:01 AM Page 80 VAC Device for Fournier’s Gangrene continued prevent leaks in the vacuum. Prior to ending the procedure, we recommend initiating the VAC device and checking for air leaks. Air leaks may be addressed at any time with additional adhesive drapes supplied by the vacuum device manufacturer, or more simply, any plastic adhesive dressing may be used. In our experience, applying benzoin ointment or stomahesive paste to the edges of the wound allows for a better attachment to the surrounding skin.10 Occasionally, the defect to which the VAC device is applied is so large that a single device may not be sufficient. In these cases, 2 may be applied without added difficulty. More commonly, there are 2 areas of skin defects that require separate sponges. Using a Y connector, the VAC device may be applied to 2 separate sponges. Air leaks, which prevent the vacuum suction necessary for function, most frequently occur in the corners of the wound and near the rectum. Adequate coverage can prove challenging even for the most experienced practitioners. Stool and ambulation may dislodge the drape and cause loss of suction. When initially applying the adhesive drape, it may be necessary to place a finger in the rectum and cut a hole in the drape around the finger in order to attain a seal around the anus. Additionally, placing nonabsorbable sutures through any deep tissue de- fects improves the contours of the wound and allows for easier sponge placement, and greater proximity to the rectum may prove useful, as it did in our case (Figure 4). In rare instances, a diverting ostomy must be placed in order to prevent the wound from being continually bathed in stool. In our hands, however, the wound vacuum system has almost entirely prevented the need for diverting ostomy, as the drape has provided protection from stool soilage. If the vacuum device must be removed or becomes dislodged, a traditional dressing can be placed in the wound until the device can be replaced. There are no reports in the literature of the vacuum device being placed in close proximity to the corpus spongiosum or the skeletonized testicles. In our experience, this was safely performed without any complication or further injury. If there is damage to the urethra or suspicion of a urethral fistula, however, placement of a wound vacuum device could theoretically prolong the fistulous tract. We have not placed a vacuum device in this situation and do not recommend it. In our experience, VAC devices have proven beneficial in patients with large soft-tissue defects in the perineum and scrotum. Though the anatomy in this region can make the placement of these devices difficult, certain techniques facilitate their application. With further experience, vacuumassisted closure will become a more frequently utilized therapeutic regimen for the treatment of genitourinary wounds. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Verit A, Verit FF. Fournier’s gangrene: the development of classical pathology. BJU Int. 2007;100:1218-1220. Yeniyol CO, Suelozgen T, Arslan M, Ayder AR. Fournier’s gangrene: experience with 25 patients and use of Fournier’s gangrene severity index score. Urology. 2004;64:218-222. Tahmaz L, Erdemir F, Kibar Y, et al. Fournier’s gangrene: report of thirty-three cases and a review of the literature. Int J Urol. 2006;13:960-967. Ayan F, Sunamak O, Paksoy SM, et al. Fournier’s gangrene: a retrospective clinical study on fortyone patients. ANZ J Surg. 2005;75:1055-1058. Moues CM, van den Bemd GJ, Heule F, Hovius SE. Comparing conventional gauze therapy to vacuum-assisted closure wound therapy: a prospective randomised trial. J Plast Reconstr Aesthet Surg. 2007;60:672-681. Rosser CJ, Morykwas MJ, Argenta LC, Bare RL. A new technique to manage perineal wounds. Infect Urol. 2000;13:45-55. Senchenkov A, Knoetgen J, Chrouser KL, Nehra A. Application of vacuum-assisted closure dressing in penile skin graft reconstruction. Urology. 2006;67:416-419. Denzinger S, Lübke L, Roessler W, et al. Vacuumassisted closure versus conventional wound care in the treatment of wound failures following inguinal lymphadenectomy for penile cancer: a retrospective study. Eur Urol. 2007;51:13201325. Whelan C, Stewart J, Schwartz BF. Mechanics of wound healing and importance of vacuum assisted closure in urology. J Urol. 2005;173: 1463-1470. Fitzmaurice M, Lawson D, Friedman H. A novel approach for the application of the vacuum assisted closure device to the difficult anatomy. J Plast Reconstr Aesthet Surg. 2006;59:1249-1250. Main Points • Fournier’s gangrene is one of the true urologic surgical emergencies and is a life-threatening condition even in the modern era. Initial treatment consists of broad spectrum antibiotics, resuscitative fluids, and aggressive surgical debridement. • Surgical debridement can leave large tissue defects that can be difficult to close even with the use of flaps and grafts. Vacuumassisted closure (VAC) devices have been demonstrated to result in more rapid closure of these wounds. • Wound VAC devices are thought to provide microstrain, which promotes more rapid wound closure by encouraging perfusion, fibroblast migration, and cell mitosis and proliferation; removing infected materials and excess exudates; reducing localized edema; and drawing wound edges together. • Wound VAC devices are underutilized by urologic surgeons. This may be due to unfamiliarity and difficulty in their placement for urogenital wounds. We outline strategies for easier placement of such devices. 80 VOL. 10 NO. 1 2008 REVIEWS IN UROLOGY