[P-074]
Cystoscopy Can Be Cornerstone Step For The Management Of Fournier’s Gangrene
Abdullah Gül1, Serdar Aykan22Bagcilar Training and Research Hospital, Department of Urology, Istanbul, turkey
INTRODUCTION: Fournier’s gangrene(FG) was first described by Jean Alfred Fournier in 1883 is a rapidly progressive and frequently fatal necrotising fasciitis of the perineum,perianal or genital areas.Predisposing factors include immuno-compromised patients.We want to present one FG case following traumatic urethral catheterization for considering what can we do when the patient has concomitant suspected bladder cancer.
Case presentation:A 55-year-old man was consulted with foul-smelling purulent discharge with urine flow from the scrotum that looks like necrotizing fasciitis was caused by urethrocutaneous fistula for 12 hours.There was a history of a unsuccessful foley catheter insertion 10 days ago for the following up urine extraction and hematuria for 2 days from condom catheter.On visual inspection it shows about 2x2,5 cm exudate in the middle of scrotum and approximately 3 cm necrotic skin surrounding this area.All necrotic tissue (figure 1a) was debrided urgently and sent for pathological examination (figure 2) while pus for culture.A traumatic urethral rupture was revealed during surgery and urethral reconstruction was performed over the silicon urethral catheter (figure 1b).Postoperatively, ultrasound-guided suprapubic cystostomy placement was planned.However,increased anterior bladder wall thickness which was suspected bladder cancer was assigned.On the 7th postoperative day,urethral fistula has been preventing the healing of debrided area which occured again (figure 1c).Upon this,cystoscopy was decided and performed.Onto bladder cancer wasn’t shown, urethral catheter was removed while suprapubic cystostomy was inserted.On the 17th postoperative day, the wound has completely gotten well (figure 1d) and plastic surgeons planned reconstruction by a flap.
DISCUSSION: FG which has frequently polymicrobial origin is a rare,but an acute urologic emergency with high mortality rates.Surgical debridement of FG must be early and complete, with adequate fluid resuscitation,electrolyte therapy and parenteral broad-spectrum antibiotic therapy.Although insertion of suprapubic catheter should be recommended in case of urethral injury we couldn’t perform due to the suspected bladder cancer.We think that cystoscopy may be cornerstone step by clarifying the doubt during this concomitant situation which there isn’t in the literature.
CONCLUSION: Urethral catheterisation should be performed by expert hands and to use a multidisciplinary approach include the urologist,colorectal surgeons,infectious disease specialist,intensive care specialists and the involvement of nurses from the beginning of FG.
Figür 1. Fournier Gangreni
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a) Necritic tissue excised b) Traumatic urethral rupture area c) Purulent urine discharge from the urethral fistula surrounding necritic tissue d) Completely healthy tissue
Figür 2. Patolojik Değerlendirme
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a) (H&E X 40) Commonly necrosis in skin - subcutaneous tissue, congestion and chronic active inflammation b) (H&E X 200) Necrosis extending to the deep muscle layer