Why are the testes and urethra (urinary tract) spared during debridement in Fournier gangrene?

Why Testes and Urethra Are Spared in Fournier Gangrene Debridement

The testes and urethra are spared during debridement in Fournier gangrene because they have a separate blood supply distinct from the affected fascial planes, which naturally protects them from the necrotizing infection and makes preservation possible during surgical debridement. 1, 2

Anatomical Basis for Preservation

Testes Preservation

• The testes receive their blood supply directly from the testicular arteries (branches of the abdominal aorta) that travel within the spermatic cord
• This deep and separate vascular supply typically remains unaffected by the necrotizing process that primarily involves superficial fascial planes
• The infection typically spreads along fascial planes of the genitalia and perineum but does not penetrate the tunica albuginea of the testes 1

Urethral Preservation

• The urethra has its own dedicated blood supply via the bulbar and cavernosal arteries
• This distinct vascular network allows the urethra to remain viable even when surrounding tissues are necrotic
• The deep anatomical location of the urethra provides additional protection from the spreading infection

Surgical Considerations

Debridement Principles

• Radical debridement with complete removal of all necrotic tissue is essential for survival 1
• Despite aggressive debridement, the testes, glans penis, bladder, and rectum are typically spared due to their separate blood supplies 2
• The Infectious Diseases Society of America and World Journal of Emergency Surgery guidelines emphasize removing only necrotic tissue while preserving viable structures 1

Urological Considerations

• Orchiectomy or other genital surgery should only be performed if strictly necessary and ideally with urologic consultation 1
• The 2021 World Journal of Emergency Surgery guidelines specifically recommend against routine orchiectomy unless absolutely required 1
• Urinary diversion via catheterization is usually sufficient, with suprapubic cystostomy reserved only for cases with urethral disruption or stricture 1

Multidisciplinary Approach

• A team approach involving general/emergency surgeons, urologists, and plastic surgeons is recommended for optimal management 1
• Decisions regarding the need for fecal or urinary diversion should be tailored to individual patient characteristics
• Subsequent reconstructive procedures may be necessary after the infection is controlled, with options including skin grafts and flaps 3

Clinical Implications

• Preservation of these structures significantly reduces long-term morbidity related to urinary and sexual function
• Despite the extensive nature of debridement required in Fournier gangrene, mortality remains high (20-43%) even with optimal management 4
• Early and aggressive debridement is the most significant prognostic factor, but preservation of vital structures like testes and urethra whenever possible is standard practice 5

Common Pitfalls to Avoid

• Delaying surgical debridement beyond 24 hours after admission significantly increases mortality 6
• Inadequate debridement of necrotic tissue in an attempt to preserve structures that are actually involved in the infection
• Unnecessary removal of viable testes or damage to the urethra due to overly aggressive debridement
• Failure to involve urological specialists when debridement involves complex genital structures