Fournier’s gangrene primary and secondary management Wound-healing techniques and treatment strategies
differentiation, anti-inflammatory and antimicrobial effects, and suppression of nociception are considered important facets of biological responses to therapeutic shock waves (7). One advantage of ESWT for wound healing represents the fact that the effect can be seen directly unlike in other urological indication such as Peyronie’s disease, erectile dysfunction, and lower urinary tract symptoms (LUTS) (11,12). The last case of complete restoration of the local skin distinguishing between scrotal and penile skin might indicate that stem cell activation might be the underlying mechanism (7). In this context, the recent studies of Tom Lue’s group are very interesting showing experimentally the proliferation of stem cells of the pelvic floor muscles in an birth injury simulation model (13). In conclusion, the positive effect of Li-ESWT on wound healing can be also very interesting for urologists dealing with secondary wound healing such as in the postoperative management of Fournier’s gangrene. References 1. Eke, N. Fournier’s gangrene: a review of 1726 cases. Br J Surg, 2000. 87: 718. 2. Mopurgo E, Galandiuk S. Fournier’s gangrene. Surg Clin North Am. 2002;1213-24.
secondary healing of skin-flaps (Fig. 2b) (9). Subsequently, we were able to close an open wound completely by Li-ESWT only in three more patients (Fig. 3a, 3b, 4). In another two cases, we used ESWT prior to plastic surgery. Patients and technique of ESWT This is a two-institutional study (Heilbronn, Manila): Eight men (aged 27 to 68 years) were admitted with severe Fournier’s gangrene requiring complete excision of the scrotal and perineal skin (Fig. 1a, 1b, 3a, 4a). They were all treated in our intensive care unit (ICU) for 10 to 14 days. Wound dressing was applied every other day. Once granulation of the wound started, we closed the wound by using the skin flap from the surrounding area in three patients. Unfortunately, they showed dehiscence of the wound during the follow-up (Fig. 2a). “The positive effect of Li-ESWT on wound healing can be also very interesting for urologists dealing with secondary wound healing such as in the postoperative management of Fournier’s gangrene.” We treated all three patients with Li-ESWT by using the electromagnetic device Duolith SD1 ultra (Storz-Medical, Taegerwilen, Switzerland) applying three times weekly (Mondays, Wednesdays, and Fridays) with 2000 shock waves at 3 Hz with an energy density of 0.25 mJ/mm2 distributed equally on the rims of the wound (Fig. 3a). The treatment was well tolerated with no need of anaesthesia or analgesia. The wounds of all three patients showed a dramatic progress in the healing process (Fig. 2b) with almost complete healing after 12 weeks. No further surgical procedure was required. Based on this, we treated three patients with complete necrosis of the scrotal and penile skin requiring radical excision (Fig. 4a, 4b, 4c) following ICU for 7 to 10 days. Since there was not much tissue available for adequate plastic surgery of penile and scrotal skin, we started to treat the patients with the Li-ESWT-protocol. Interestingly, all three patients responded very well on the treatment starting with intensive granulation tissue covering the wound after six weeks (Fig. 4b). Even more impressive, we were able to close the entire wound after 12 weeks (Fig 2d) without any surgical procedure. This was not due closure by just fibrotic tissue. Instead, the locally present scrotal skin was restored as well as the penile skin with an optimal cosmetic result after three months (Fig. 4c) Discussion There have been several attempts to improve the wound healing after complete surgical excision in case of Fournier’s gangrene. A more recent comparative case series suggested the benefit of using hyperbaric oxygen therapy in 16 patients compared to 12 cases without the use of said therapy in terms of reduced mortality and fewer debridements (4). A low-quality randomised controlled trial (RCT) with 30 patients found that use of honey-soaked dressings resulted in a shorter hospital stay (28 vs. 32 days) compared to dressing soaked with Edinburgh solution of lime (5). No evidence of benefit in the use of negative-pressure (vacuum) wound therapy in Fournier’s gangrene was found (3). Already in 1990, Haupt et al. examined the effect of shock waves on wound healing in an in-vivo porcine model using the Dornier XL1-experimental lithotripter and concluded that low energy levels (14 kV) coincided with an increased vascularization (10). In 2007, Schaden et al. initiated the first trials on Li-ESWT for wound healing (6). In the meantime, several experimental and clinical studies documented an accelerated tissue repair and regeneration in various wounds following ESWT (7, 8). However, the biomolecular mechanism by which this treatment modality exerts its therapeutic effects still remains unclear. Potential mechanisms include initial neovascularization with ensuing durable and functional angiogenesis. Furthermore, recruitment of stem cells, stimulated cell proliferation and
6. Schaden W, Thiele R, Kölpl C, Pusch M, Nissan A, Attinger CE, Maniscalco-Theberge ME, Peoples GE, Elster EA, Stojadinovic A. Shock wave therapy for acute and chronic soft tissue wounds: a feasibility study. J Surg Res. 2007;143(1):1-12 7. Mittermayr R, Antonic V, Hartinger J, Kaufmann H, Redl H, Téot L, Stojadinovic A, Schaden W. Extracorporeal shock wave therapy (ESWT) for wound healing: technology, mechanisms, and clinical efficacy. Wound Repair Regen. 2012;20(4):456-65. 8. Taheri P, Shahbandari M, Parvaresh M, Vahdatpour B. Extracorporeal Shockwave Therapy for Chronic Venous Ulcers: A Randomized Controlled Trial. Galen Med J. 2021 Apr 25;10:e1931. doi: 10.31661/gmj.v10i0.1931. eCollection 2021. 9. Rassweiler JJ, Scheitlin W, Goezen AS, Rassweiler- Seyfried MC. Low-energy Shockwave Therapy in the Management of Wound Healing Following Fournier's Gangrene. Eur Urol Open Sci. 2022 Sep 13;45:8-11. 10. Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M. Influence of shock wave healing. Urology 1992; 39: 529-532 11. Rassweiler J: Re: Extracorporeal shock wave therapy (ESWT) in Urology: A systematic review of outcome in Peyronie`s disease, erectile dysfunction, and chronic pain. (Words of Wisdom) Eur Urol 2018; 74: 115-117 12. Sokolakis I, Pyrgidis N, Neisius A, Gierth M, Knoll T, Rassweiler J, Hatzichristodoulou G, on behalf of the German Society for Shock Wave Lithotripsy. The effect of low-intensity shock wave therapy on non-neurogenic lower urinary tract symptoms. A systematic review and meta-analysis of pre-clincal and clinical studies. Eur Urol Focus 2022 May;8(3):840-850 13. Lin G, Van Kuiken M, Wang G, Banie L, Tan Y, Zhou F, Wang Z, Chen Y, Zhang Y, Lue TF. Microenergy acoustic pulse therapy restores function and structure of pelvic floor muscles after simulated birth injury. Transl Androl Urol. 2022 May;11(5):595-606. doi: 10.21037/tau-22-30.
Prof. Jens Rassweiler Chair of Urology and Andrology Danube Private University, Krems (AT)
jens.rassweiler@ gmail.com
Co-authors: Scheitlin, W 2 , Hatiboglu G 2 , Agatep J 3 , Condendo C 3 , Goezen AS 4 , 2 Department of Urology, SLK Kliniken Heilbronn, Germany, 3 Department of Urology, East Avenue Medical Center, Manila, Phillipines, 4 Department of Urology, Medius-Klinik, Ostfildern-Ruit Fournier’s gangrene is an aggressive and frequently fatal polymicrobial soft tissue infection of the perineum, peri-anal region, and external genitalia (Fig. 1a). It is an anatomical sub-category of necrotising fasciitis with which it shares a common etiology and management pathway [1, 2]. Typically, there is painful swelling of the scrotum or perineum with sepsis. Examination shows small necrotic areas of skin with surrounding erythema and oedema. Crepitus on palpation and a foul-smelling exudate occurs during the advanced stage of the disease [3]. Risk factors include diabetes mellitus, malnutrition, immunotherapy, alcohol abuse, recent urethral or perineal surgery, and high body mass index. The degree of internal necrosis is usually vastly greater than suggested by external signs. It requires immediate radical surgery with complete removal of affected tissue (Fig. 1b). Once the patient is stabilized and the wounds are clean, postoperative management includes mesh-graft and skin-flaps (1-3). Options for secondary management Both can be associated with secondary wound healing problems mostly requiring secondary surgical procedure (Fig. 2a). Moreover, the cosmetic results of mesh-grafts are not convincing. Other alternatives have been tested, such as hyperbaric oxygen therapy, application of honey, and vacuum- techniques (3-5). Based on the promising results with the use of low-intensity extracorporeal shock wave therapy (Li-ESWT) in the management of chronic ulcers (6-8), we initially used Li-ESWT in three cases with
3. G. Bonkat, R. Bartoletti, F. Bruyère, T. Cai, S.E. Geerlings, B. Köves, S. Schubert, A. Pilatz, R.
Veeratterapillay, F. Wagenlehner. EAU-Guidlines on Urological Infections. European Association of Urology 2022 4. Mladenov A, Diehl K, Müller O, von Heymann C, Kopp S, Peitsch WK. Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years. World J Emerg Surg. 2022 Aug 5;17(1):43. 5. Subrahmanyam, U., Ugane SP. Honey dressing beneficial in treatment of fournier’s gangrene. Indian J Surg, 2004. 66: 75.
Friday 10 March 13:03 - 13:13 Thematic Session: Emergencies in urology Yellow Area, eURO Auditorium 2
EUREP23 21st European Urology Residents Education Programme www.eurep23.org 1-6 September 2023, Prague, Czech Republic
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European Urology Today
February/March 2023
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