Validation Of The Fournier's Gangrene Severity Index In A Large Contemporary Series

Main Category: Urology / Nephrology
Article Date: 17 Oct 2008 - 2:00 PDT


UroToday.com - Fournier's Gangrene (FG) has historically been defined as a fulminant necrotizing fascitis of the male genitourinary tract. However, a similar condition of the female perineum is commonly encountered in clinical practice. Applying the same pathologic process to both sexes, a more modern definition includes any progressive necrotizing infection of the perineum.

Contemporary FG series have described a mortality rate of 20 to 43%, often due to the severe sepsis that occurs in almost 50% of patients^1-6. With such a high mortality rate the mainstay treatment of FG remains immediate surgical debridement, broad-spectrum intravenous antimicrobial coverage and supportive critical care therapies. Perhaps due to advances in critical care and antimicrobial therapies, we reported a mortality rate of 10% during initial hospitalization with an overall mortality rate of 13%. Using total body surface area involved from methods commonly used in burn patients, our mean TBSA was similar to other reported series indicating the degree of FG involvement was comparable to those series^{2, 4, 6}.

With such a wide range of reported mortality rates, accurate prognostication of the outcome at the time of patient presentation is extremely difficult. When asked by family members to quantify the severity of FG and the chance of survival, physicians usually rely on clinical judgment derived from the physiologic and laboratory data available. One tool that uses these commonly available parameters to better quantify risk in this complex patient population is the Fournier's Gangrene Severity Index (FGSI). First described by Laor, et al. in 1995², it is a numerical score obtained from the patient's temperature, heart rate, respiration rate, sodium, potassium, creatinine, white blood count, hematocrit and sodium bicarbonate. Several series have described a threshold at which the FGSI score can predict mortality with varying results^{1, 2, 4, 6}, while another reported the FGSI is not valid⁴. In this paper, we focus on the FGSI score at the time of presentation and use it to predict mortality during the initial hospitalization. We report one of the largest series of FG patients to date and attempt to validate the FGSI and threshold score in a contemporary series.

Our data supports the validity of the FGSI and the originally described threshold value of 9. At a score of less than 9, the patient has a 96% chance of survival. However, a score greater than or equal to 9, the patient has a 46% mortality rate (sensitivity 71.4%, specificity 90%). Calculation of the FGSI can be quickly performed from readily available information. This information can then be utilized in counseling family members to convey an objective measure of the severity of the disease process, degree of urgency in treatment and prognosis during hospitalization. Following this study, we have started to utilize this in clinical practice and have found it to be a valuable tool. In fortunate cases, we have witnessed the relief family members take in our reassurance of a favorable prognosis. In the unfortunate minority of cases where the FGSI is 9 or greater, we have counseled families that the condition is potentially grave with a 50% chance of survival and have been thanked for our honesty. Therefore, we believe the FGSI should not be purely academic and should be calculated for all FG patients and the data shared with family members.

Written by Anthony T. Corcoran, MD, as part of Beyond the Abstract on UroToday.com.

References 1. Ersay, A., Yilmaz, G., Akgun, Y. et al.: Factors affecting mortality of Fournier's gangrene: review of 70 patients. ANZ J Surg, 77: 43, 2007

2. Laor, E., Palmer, L. S., Tolia, B. M. et al.: Outcome prediction in patients with Fournier's gangrene. J Urol, 154: 89, 1995

3. Spirnak, J. P., Resnick, M. I., Hampel, N. et al.: Fournier's gangrene: report of 20 patients. J Urol, 131: 289, 1984

4. Tuncel, A., Aydin, O., Tekdogan, U. et al.: Fournier's gangrene: Three years of experience with 20 patients and validity of the Fournier's Gangrene Severity Index Score. Eur Urol, 50: 838, 2006

5. Unalp, H. R., Kamer, E., Derici, H. et al.: Fournier's gangrene: Evaluation of 68 patients and analysis of prognostic variables. J Postgrad Med, 54: 102, 2008

6. Yeniyol, C. O., Suelozgen, T., Arslan, M. et al.: Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score. Urology, 64: 218, 2004

UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice.

To access the latest urology news releases from UroToday, go to: www.urotoday.com

Copyright © 2008 - UroToday

• Additional
• References
• Citations