Retroperitoneal necrotizing fasciitis with gas gangrene caused by urethral stricture.

Introduction

Necrotizing fasciitis is a rapidly spreading necrotizing infection of the subcutaneous tissues. It is an extremely rare condition and the bibliography data are very stingy about this disease. The precise etiology of necrotizing fasciitis is not resolved satisfactorily.

Case report

Our patient is a 60-year-old-man. He consulted his general practitioner in a local health clinic for an acute urine retention. We put him up a Foley catheter CH 12. The retrograde urethrocystography which was done the next day showed an urethral stricture surrounded by an addition image (Fig. 1). The bladder catheter was replaced by a suprapubic catheter due to the discomfort of the patient. A few days later, he presented to our emergency department with the chief complaints of fever and hypogastric pain. The physical examination founded an elevated temperature of 38.5 °C and a tachycardia at 110 beats per minute. A tenderness was noted in the subumbilical floor. Subcutaneous crepitus was not noticed. Complementary investigations showed hyperleucocytosis (WBC = 21520 cells/mm3) and hyperglycemia (G = 3g/L). Renal function was normal. The patient had a scanner which revealed a pelvic abscess in the retropubic space. A retroperitoneal collection and necrotizing fasciitis limited to the retroperitoneum with retroperitoneal emphysema was found (Fig. 2, Fig. 3). We decided to operate the patient. He underwent an infraumbilical midline incision, evacuation of the abscess and placement of a drain which brought 600 cc of pus. He was put on intravenous broad spectrum antibiotics. The general condition of the patient did not improve and we decided to intervene 4 days later. Exploratory laparotomy demonstrated a phlegmon with extensive necrosis of the retroperitoneum. Crepitation and a brown turbid fluid were noticed. The patient underwent debridement of the retroperitoneal tissues and excision of the necrosis. We placed a corrugated retroperitoneal drain and a pelvic tube drain. Fever was alleviated by treatment with the same antibiotics. The drains were removed after 3 weeks. The patient was discharged from the hospital 5 weeks after his initial surgery. He was fine at the clinical control practiced one month later. The endoscopic surgical treatment of the urethral stricture was performed 12 weeks after the acute episode and the patient had an internal urethrotomy. At 6 months after initial surgery, he is asymptomatic with rather satisfying micturition.

Fig. 1

The retrograde urethrocystography showed an urethral stricture with an addition image.

Fig. 2

Emphysema in the pelvic floor.

Fig. 3

Retroperitoneal emphysema behind the right kidney.

Discussion

Retroperitoneal necrotizing fasciitis with gas gangrene is a soft tissue infection leading to necrosis. It occurs mostly in the immunocompromised patient. The diagnosis is made by the computed tomography which highlights the presence of gas. Early and aggressive surgery is mandatory as well as immediate antibiotic therapy. Although extensive repeated debridement, the mortality of retroperitoneal necrotizing fasciitis is very high. In our case, we treated the starting point of this pathology. Gas gangrene with urinary departure is extremely rare and requires the surgical treatment of the obstacle if the evolution of this major surgery is favorable.

Conclusion

Retropertitoneal necrotizing fasciitis with gas gangrene is an extremely rare and life-threatening condition that needs early diagnosis, extensive debridement, and full coordination with anesthetist team. Immediate and aggressive surgery is essential for vital prognosis. If the starting point is urinary, the surgical treatment of the obstacle is mandatory.

Conflicts of interest

The authors declare that there are no conflicts of interests regarding the publication of this article.