In an adult male with Fournier's gangrene and loss of scrotal tissue (diabetes, obesity, immunosuppression), how can the viable testes be temporarily placed in a well‑vascularised thigh pouch?

Temporary Testicular Placement in Thigh Pouches After Fournier's Gangrene Debridement

When extensive scrotal tissue loss (>50%) precludes primary closure after Fournier's gangrene debridement, temporarily relocate the viable testes into anteromedial thigh pouches to allow the residual scrotal skin to heal and close, then gradually massage the testes back into the expanded scrotal pouch over 3–8 months. 1

Surgical Technique and Timing

When to Use Thigh Pouches

• Create anteromedial thigh pouches when more than 50% of scrotal skin has been lost during serial debridement, making delayed primary closure over the testes impossible. 1
• Perform this procedure only after achieving healthy granulation tissue through serial debridement (typically 2–3 debridements performed every 12–24 hours until necrotic tissue is eliminated). 2, 1
• The testes themselves are rarely involved in Fournier's gangrene due to their separate blood supply from the spermatic cord, so orchiectomy should be avoided unless absolutely necessary based on urologic consultation. 2

Operative Steps

• Dissect subcutaneous pouches in the anteromedial thigh region bilaterally, creating well-vascularized pockets. 1
• Place each testis into its respective thigh pouch after the scrotal wound has been adequately debrided and dressed. 1
• Close the residual scrotal skin primarily once the testes are relocated, allowing the wound to heal without tension. 1
• Plan for gradual manual massage of the testes back into the residual scrotal pouch postoperatively, which acts as natural tissue expansion over 3–8 months. 1

Expected Outcomes and Follow-Up

Functional and Cosmetic Results

• Normal testicular volume is maintained in all patients using this technique (mean testicular volume 19.0 ± 3.2 cm³). 1
• The residual scrotal pouches expand sufficiently over time to accommodate both testes without specialized reconstructive surgery. 1
• This approach eliminates the need for complex flap reconstruction or immediate skin grafting while preserving testicular function. 1

Hospital Course

• Mean duration of admission is approximately 24 days for patients requiring thigh pouch placement. 1
• Mean number of debridements before thigh pouch creation is 2–3 procedures. 1
• Mortality is not increased by this technique when performed in appropriately selected patients with Fournier's Gangrene Severity Index scores averaging 6.0. 1

Alternative Reconstructive Options

When Thigh Pouches Are Not Appropriate

• If scrotal skin loss is less than 50%, delayed primary closure of residual scrotal skin over the testes can be attempted without thigh pouches. 1
• For patients who cannot tolerate the 3–8 month expansion period, alternative immediate reconstruction includes split-thickness skin grafts with a "bagging technique" where testes are wrapped in grafts and vacuum-assisted closure is applied. 3, 4
• Pedicled gracilis muscle flaps provide well-vascularized coverage for large scrotal defects with deep pockets, offering greater resistance to infection and a good bed for subsequent skin grafting. 5

Critical Management Principles

Multidisciplinary Coordination

• Early involvement of urology, general surgery, and plastic surgery is essential for planning testicular preservation and reconstruction strategies. 2, 6
• Urologic consultation should guide decisions about testicular preservation versus orchiectomy, with the strong preference being preservation whenever viable. 2

Avoiding Common Pitfalls

• Do not attempt primary scrotal closure over the testes when more than 50% of scrotal skin has been lost—this leads to wound dehiscence and exposed testes requiring emergency revision. 1
• Do not perform orchiectomy reflexively; the testes have a separate blood supply and are usually spared even in extensive Fournier's gangrene. 2
• Do not rush to complex flap reconstruction in the acute setting; thigh pouches provide a simpler temporizing solution that preserves all reconstructive options. 1