Towards zero mortality in Fournier's gangrene.

The authors present a retrospective analysis of their 20 patients treated for Fournier's gangrene (FG) within three years in one urological department. This is the largest series known to us collected during 3 years in a single institution [1]. However, to give a reference scale, authors should have presented data on the total number of hospital admissions per year as well.

Looking at the clinical data one may be surprised with a number of ablative procedures. With six orchiectomies (30%) and three penectomies (15%) this group represents one of the highest rates reported in contemporary literature (Table 1). Orchiectomy should be carried out only if a testicle is involved in the necrotic process and its vitality is questioned. Severe infection of the peritesticular tissues does not always correspond with the involvement of the testis [2] so that the ablative surgery is rarely justified. Decision however depends on the experience of a surgeon. Fournier's gangrene involving penis to the extent that penectomy has to be performed is extremely rare in our experience and in other series (Table 1). Even cases with severe necrosis of penile skin usually may be treated with repeated debridement [3], so we consider three partial penectomies is this material as a high rate.

Table 1

Procedures accompanying FG debridement and mortality rates in contemporary series

	Country	N	Orchiectomy	Penectomy	Cystostomy	Colostomy	Mortality
Katib A et al. [1]	Saudi Arabia	20	30%	15%	5%	0%	0%
Sugihara T et al. [4]	Japan	379*	10.8%	8.8%	11.5%	17.1%
Vargas AH et al. [5]	Columbia	42	9.5%	2.4%	62%	14.3%	17%
Kuo CF et al. [6]	Taiwan	44	2.3%	2.3%	2.3%	4.6%	22.7%
Koukouras D et al. [7]	Greece, Germany	45**	26.7%	0%	37.8%	55.5%	15.6%

Data from Japanese urological departments

Data from three departments

On the other hand, in contrast to Katib and other authors we are creating suprapubic percutaneous cystostomy as standard when treating patients with significant defects of skin in genital area.

In a brief review of recent FG series presented in Table 1 one can find that types of procedures used and results of treatment vary significantly between the centers. The highest rate of orchiectomies and penectomies present Katib and coworkers. In the same time they acquire 0% mortality, the best result of all studies cited.

Of course differences in FG definition, case severity and experience of surgical and medical teams also affect the outcome. Nonetheless effect of surgical aggressiveness should be investigated further.