Transurethral resection of the prostate among medicare beneficiaries: 1984 to 1997. For the Patient Outcomes Research Team for Prostatic Diseases

PURPOSE: Urethrovaginal fistulas are commonly repaired transvaginally with local tissue flaps, such as the Martius labial fat pad graft. Although this flap is ideal, if it fails and the fistula persists, subsequent treatment options are limited. We describe the use of a pedicled rectus abdominis muscle flap for the repair of complex and refractory urethrovaginal fistulas. MATERIALS AND METHODS: Six women with a mean age of 53 years (range 41 to 62) who had complex and refractory urethrovaginal fistulas were referred to our continence center. Mean number of prior attempted repairs was 1.3 and in all cases at least 1 Martius flap had failed. Transvaginal urethrovaginal fistula closure was performed followed by a pedicled rectus abdominis muscle flap interposed between the fistula closure and vaginal suture line. The muscle flap was based on the inferior epigastric vessels, and provided additional support to the urethra, bladder neck and bladder base. RESULTS: Urethrovaginal fistula repair with the rectus abdominis muscle flap was successful in all cases. No fistula recurred. Of the patients 5 (83%) were continent and able to void to completion at a mean followup of 23 months (range 2 to 66). CONCLUSIONS: The rectus abdominis muscle flap is a useful adjunct in the repair of complex and refractory urethrovaginal fistulas. It can be used with confidence to provide support to the bladder neck and proximal urethra in patients after failed prior repair with the Martius flap procedure. The pelvic surgeon may be able to recognize other applications for the rectus abdominis muscle flap in pelvic floor reconstruction.     

Fournier's gangrene. Report of three cases and review of the literature

Fournier's gangrene, or synergistic gangrene of the male external genitalia is a rapidly spreading necrotising infection of the penis and scrotum. Although not so frequent in our civilized world it is by no means rare. In early days it was characterised by a high mortality. Aggressive surgical debridement, broad spectrum antibiotics and plastic reconstructive technics have all contributed to a better survival of the patients.     

暴发性阴囊坏疽的局部处理方法探讨

目的 探索暴发性阴囊坏疽的治疗方法。方法 回顾分析9例暴发性阴囊坏疽治疗方案。9例患者均行外科清创，冲洗引流，抗感染等治疗，其中4例感染广泛蔓延的患者清创术后，采用U形多孔双向引流管引流。3例外暴露的睾丸暂置于浅表腔隙中，二期重建阴囊回纳睾丸。结果 留置U形管引流者，重复清创手术的次数明显减少，体温及血象恢复正常的时间较普通引流显著缩短，术后恢复迅速。结论 暴发性阴囊坏疽的治疗仍以清创及应用抗生素为主，术中多毋须切除睾丸。U形多孔双向引流管在清创术后引流效果确切，在促进康复有明显优势。     

A technique using a rectus abdominis muscle flap in the treatment of adult congenital tracheoesophageal fistulas

The authors successfully treated an adult with congenital tracheoesophageal fistula (TEF) Gross-C type by the addition of an effective pedicled muscle flap. This patient had undergone 2 thoracotomies when he was an infant at another hospital; however, the fistula recurred. After transection and closure of the fistula, a right rectus abdominis muscle flap between the 2 stumps was interposed. The current case followed a favorable postoperative course; neither fistula nor abdominal hernia occurred.     

Scrotal reconstruction with a thinned flap based on both inferior epigastric arteries. Case report.

A 62-year-old man presented with an extensive defect of the scrotum caused by Fournier's gangrene. We reconstructed the scrotum using a thinned flap based on both inferior epigastric arteries one month after the first debridement. This method has the advantage of achieving adequate mobility of the reconstructed scrotum. The results were satisfactory both functionally and cosmetically, although we had to repair a hernia at the donor site a year later.     

Pedicled rectus abdominis muscle flap wrapped around the penis for enhanced urethral pressure: an experimental study in dogs

PURPOSE: It was the aim of this study to investigate the possibility of pedicled rectus abdominis muscle fascial flap wrapped around the penis for enhanced urethral pressure in dogs. MATERIALS AND METHODS: Ten adult male Beagle dogs underwent a procedure in which surrounding tissue of the penis at the site of the bulbomembranous urethra was dissected and a pedicled rectus abdominis muscle fascial flap was wrapped around the penis. Profilometry of the urethral pressure was carried out before, during and after the operation in all dogs. RESULTS: Before the operation, the mean maximal urethral pressure (MUP) was 48.9 +/- 11 cm H(2)O, and the mean MUP was 78.3 +/- 20.5 cm H(2)O after the penis was surrounded by a rectus muscle flap. There was a significant difference (t = 4.99, p = 0.0007). Ten weeks after the operation, the mean MUP was 88.3 +/- 22.4 cm H(2)O, which was significantly higher than that before the operation (t = 6.0584, p = 0.0002). CONCLUSIONS: A pedicled rectus abdominis muscle fascial flap wrapped around the penis can raise the urethral pressure. This provided an experiment basis for treating male urinary incontinence with a pedicled rectus muscle flap.     

A case of Fournier's gangrene: was it triggered by prostatic massage?

We have experienced a case of Fournier's gangrene which progressed rapidly after prostatic massage. The patient was a 70-year-old man who had poorly controlled diabetes mellitus, hemorrhoid, urethral stricture and benign prostatic hyperplasia. He visited an urologist complaining of pollakisuria and miction pain. Under the diagnosis of prostatitis, prostatic massage was performed. From that night, he developed a high grade fever. Simultaneously, redness, swelling and pain of the scrotum progressed rapidly, and 11 days later, he was admitted to our hospital. An X-ray examination revealed subcutaneous gas formation in the scrotum. Immediately, incision and drainage with extensive debridement of necrotic tissue were performed combined with chemotherapy using broad spectrum antibiotics and insulin therapy. About 3 months later, the gangrene and the wound were healed with granulation and scarring. Cultures of the pus and the necrotic tissue from the scrotum were positive for Bacteroides fragilis and several aerobes including Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterococcus and Staphylococcus epidermidis. The case proved to be non-clostridial gas gangrene.     

腹直肌蒂胸骨瓣翻转成形术

采用腹直肌蒂胸骨瓣翻转成形术治疗漏斗胸8例。手术要点在于充分游离腹直肌,切断肋软骨时尽量保留软骨膜的完整,慎勿损伤腹直肌的肋软骨附着部及腹壁上动脉。8例术后胸骨凹陷完全矫正,胸廓外形恢复正常。经半年以上随访,患儿活动量明显增加,X 线复查胸骨与肋骨断端已完全愈合。     

Two-stage reconstruction of infected deep median sternotomy wound with an intercostal pedicled oblique rectus abdominis musculocutaneous flap after coronary artery bypass grafting

Median sternotomy wounds infected after coronary artery bypass grafting with bilateral internal mammary arteries are generally poor in condition, cannot be debrided adequately, and are limited in flap selection for reconstruction. The authors treated 2 patients with two-stage reconstruction using a modified superior-based rectus abdominis musculocutaneous flap. First, simple debridement was performed with the goal of preserving the internal mammary artery grafts. Then, delayed reconstruction with the oblique rectus abdominis musculocutaneous flap supplied by the superior epigastric and seventh intercostal vessels was performed. Despite ligature of the bilateral internal mammary arteries at their full length, the large oblique skin paddle designed along the angiosome as far as the midaxillary line survived almost completely in both patients, resulting in cessation of pus discharge. The circulation to the superior epigastric and intercostal vessels might be reinforced because of the delay phenomenon. Two-stage reconstruction with a superior pedicled oblique rectus abdominis musculocutaneous flap presents a successful resolution of infected median sternotomy wounds after coronary artery bypass grafting with sacrifice of bilateral internal mammary arteries.     

暴发性阴囊坏疽治疗9例体会

目的：探讨暴发性阴囊坏疽的治疗方法。方法：对9例患者均行外科清创、冲洗引流、抗感染等治疗，其中3例外暴露的睾丸暂置于浅表腔隙中，二期重建阴囊回纳睾丸，1例患者行高压氧治疗。结果：留置U形管引流者，重复清创手术的次数明显减少，体温及血常规恢复正常的时间较普通引流显著缩短，术后恢复迅速。结论：暴发性阴囊坏疽的治疗仍以清创及应用抗生素为主，术中多无须切除睾丸；条件许可，可配合高压氧治疗；U形多孔双向引流管在清创术后引流效果确切，对促进康复有明显优势。     

Chest wall reconstruction of severe mediastinitis with intercostal artery-based pedicled vertical rectus abdominis muscle flap with oblique-designed skin pedicle

Recurrent poststernotomy mediastinitis has significant morbidity and mortality. Reconstructive treatment begins with pectoral muscle or omental flaps. When these options are unavailable or inadequate, surgeons resort to internal mammary artery-based vertical rectus abdominis muscle flap. If the internal mammary artery is harvested for coronary artery bypass grafting, surgeons are reluctant to use the muscle for pedicled flap because of the elevated risks. However, recent reports suggest that if enough time passes for intercostal artery collaterals to develop, they would support the viability of the flap. Moreover, recent improvements in defining flap microvasculature and proposed surgical techniques have enabled us to further refine the procedure. Although it appears that the intercostal artery-based pedicled vertical rectus abdominis muscle flap with oblique-designed skin pedicle is safe and effective for chest wall reconstruction, potential for failure remains elevated until sample size accumulates.     

Extensive Fournier's gangrene: a case report

We report a case of extensive Fournier's gangrene that could not be rescued despite emergent debridement. A 51-year-old man presented at another hospital with cough, diarrhea and abdominal pain. He was diagnosed with acute enteritis and hospitalized. The next morning, he became severely hypotensive and his scrotum was swollen and black. The perineal skin also was black. Septic shock and disseminated intravascular coagulation were suspected. He was transferred to our emergency room, and was immediately diagnosed with Fournier's gangrene and acute peritonitis. Computed tomographic scan revealed soft-tissue gas in the scrotum, the retroperitoneal cavity and the abdominal wall. Emergent debridement and laparotomy was performed. Gangrene was also seen at the intestinal wall and the peritoneum, however, resection of intestine was not done because of his poor performance status. Although potent antibiotics and catecholamine were administered, he died of multiple organ failure 29 hours after the operation. This is the first case of Fournier's gangrene extending into the abdominal cavity reported in the Japanese literature.     

Minimal debridement in the treatment of Fournier's gangrene.

Scrotal and perineal gangrene of the male genitalia was first described by Fournier in 1883. Treatment of the disease remains surgical despite the availability of modern antibiotics. Many authors advocate a wide debridement of all tissue superficial to the involved fascial layers. We have reviewed our experience of using wide and minimal debridement as the surgical technique of choice. In our retrospective study, nine patients were diagnosed and treated over a 2-year period for Fournier's gangrene. The mean age was 65+/-28 years. Two patients were admitted from chronic care facilities, four were diabetic, and two had taken oral steroids. Five of the nine patients were treated with the technique of minimal tissue debridement. In brief, the scrotum was bivalved along the median raphe, each scrotal sac was drained, and the testicles were exteriorized. Orchiectomy was performed if the testicles were grossly necrotic. Penrose drains were inserted from each scrotal sac to the counterincision at the level of the internal rings. All of the tissue involved was irrigated with betadine and peroxide, after debridement of the necrotic tissue. Broad-spectrum antibiotics along with daily packing were continued for 4 to 6 weeks; at the end of that time the testicles were returned to the scrotum and the skin was loosely reapproximated. Three of the nine patients were treated with wide debridement of all the soft tissue including the fascia. One of the patients displayed gangrene of the entire abdominal wall; he was not a surgical candidate and died 3 days later. The four patients treated with minimal debridement all obtained successful treatment of their fasciitis. However, one died of complications related to a duodenal ulcer. The mean hospital stay was 45+/-10 days. Two of the three patients treated with wide debridement required plastic reconstruction using a skin-muscle flap of the perineum. The remaining patient treated with wide debridement died of complications related to metastatic renal carcinoma. The mean hospital stay of this group was 62+/-12 days. The specific flora included: Bacteroidis fragilis in 87 per cent, Peptostreptococcus and Streptococcus in 75 per cent, Clostridia group, Escherichia coli, Enterobacter and Pseudomonas in 62 per cent, Klebsiella in 50 per cent, Staphylococcus in 37 per cent, and Proteus in 12 per cent of the patients. In the surgical management of Fournier's gangrene, wide drainage with minimal debridement resulted in similar morbidity and shorter hospital stay when compared with extensive debridement.     

The deep inferior epigastric rectus abdominis muscle and myocutaneous free tissue transfer: further applications for head and neck reconstruction.

The rectus abdominis muscle and myocutaneous free tissue transfer is a well-recognized donor site for reconstruction of complex head and neck defects. Four composite deformities were successfully managed using this donor site. The rectus abdominis myocutaneous "sandwich" flap was used for closure of a pharyngocutaneous fistula and to provide intraoral lining and external coverage for a composite mandibular defect. The rectus muscle flap was used to obliterate a compound frontal sinus injury and an orbitomaxillary defect. All flaps were based on the deep inferior epigastric vascular pedicle.     

The dissection of the rectus abdominis myocutaneous flap with complete preservation of the anterior rectus sheath.

Harvesting the rectus abdominis myocutaneous flap results in defects in both the rectus abdominis muscle and the anterior rectus sheath, which may be circumvented by dissecting a perforator flap (DIEP flap) instead. However, the latter is associated with a reduction in the number of myocutaneous perforators nourishing the flap, which has been hypothesised to lead to an increased risk of partial flap failure. We present a technical modification that maintains all the feeding perforators within the flap while fully preserving the anterior rectus sheath. The anterior rectus sheath is incised along a line connecting the perforators. A muscle cuff including all the feeding perforators was raised with the flap. This technique was used in 20 consecutive patients. Nine patients underwent free TRAM flap transfers for breast reconstruction (10 flaps), and 11 patients underwent thoracic-wall reconstruction with a superiorly based pedicled flap. The median follow-up was 11 months. One patient with a pedicled flap developed a partial failure that required surgical revision; all other flaps healed spontaneously. One patient in each subset had preoperative abdominal-wall laxity that was partly corrected after surgery; no abdominal bulging or hernia occurred in the other patients. Our results suggest that the technical modification presented here may enable the surgeon to dissect a rectus abdominis myocutaneous flap with maximal perforator-related flap perfusion and minimal donor-site morbidity. An advantage over the DIEP flap is that this technique is applicable to both free and pedicled flaps.     

Fournier's gangrene of the penis: a report of two cases

Fournier's gangrene is a rare disease involving the scrotum and penis with occasional extension up the abdominal wall. Both of our cases were unusual in that only the penis was involved. In addition, the occurrence of squamous cell carcinoma in an area previously affected by Fournier's gangrene has never been reported. The usual organism is an anaerobic streptococcus synergistic with some second organism. Early therapy is key, including debridement of the entire shaft of the penis distal to the devastated area, intravenous broad-spectrum antibiotics, and skin grafting.     

Fournier坏疽1例报告并文献复习

目的:探讨Fournier坏疽(fournier’s gangrene,FG)的病因、诊断要点和治疗方法,提高对该疾病的认识。方法:回顾性分析我院收治的1例FG患者的资料,并复习相关文献。结果:患者阴囊、会阴部、阴茎皮肤完全坏疽,经过积极的手术清创引流,使用足量广谱抗生素,全身支持治疗,在创面无明显炎症反应并长出新鲜肉芽组织后,行植皮术重塑阴囊、会阴部、阴茎皮肤,患者治愈出院。结论:FG病情凶险,病死率高,应早期诊断,一旦确诊应积极采取手术清创(切开)引流和广谱(敏感)抗生素治疗,如有皮肤缺损,应在创面无炎性渗出并长出新鲜肉芽组织后,及时行植皮或皮瓣转移术闭合皮肤缺损。     

Fournier's gangrene: a case report

Since necrotizing fasciitis of the genitalia was first described by Fournier in 1883, approximately 400 cases have been reported. It has been seldom reported in Japan. Because its mortality rate is still high, the importance of early diagnosis and the subsequent vigorous treatment has been emphasized. A 73-year-old man who had poor controlled diabetes mellitus was admitted to our hospital with painful swelling of scrotum. Chemotherapy using broad spectrum antibiotics and debridement of scrotal skin was performed combined with insulin therapy. As culture of pus and excised tissue from the gangrenous patches yielded the growth of candida, we used 8 g/day of 5-fluorocytosine. Because the gangrene was not healed, we performed bilateral orchiectomy. After the operation, the gangrene was healed and the wound was closed. Diabetes mellitus was controlled well and his general condition was improved.     

Fournier坏疽五例报告

目的 探讨Ｆｏｕｒｎｉｅｒ坏疽的诊断和处理方法。方法 报告５例Ｆｏｕｒｎｉｅｒ坏疽的临床特点并进行文献复习。结果 ５例经清创引流,抗炎及对症治疗第,３例康复,随访１年无复发;死亡２例;结论Ｆｏｕｒｎｉｅｒ坏疽是一种累及阴囊、阴茎的感染性坏死性筋膜炎。及时正确的诊断,处理可减少其死亡率和并发症;超声显像,ＣＴ等技术有利于此病的早期发现;治疗原则为早期清创,引流,全身应用大剂量广谱抗生素等。     

Mesh assisted direct closure of bilateral TRAM flap donor sites.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a popular choice for patients requesting breast reconstruction. Criticism of all techniques that harvest the rectus abdominis muscle centre on abdominal wall weakness.[Dulin WA, Avila RA, Verheyden CN, Grossman L. Evaluation of abdominal wall strength after TRAM flap surgery. Plast Reconstr Surg 2004; 113: 1662-1665] Primary fascial closure of the donor site has been shown to reduce abdominal wall weakness and the subsequent risk of hernia and bulge. [Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg 1994; 21: 255-272]2 Primary fascial closure of all uni-lateral and most bilateral muscle preserving TRAM flap donor sites is possible. In a series of 23 bilateral TRAM flaps, excessive abdominal tension prevented direct fascial closure of the donor site in seven. Using a technique that includes muscle preservation, muscle relaxation and mesh assistance; tensionfree, direct fascial closure was achieved in all. The mesh buttress supports the rectus sheath during closure and provides long term shape and stability.