Reconstruction of infected and denuded scrotum and penis by combined application of negative pressure wound therapy and split‐thickness skin grafting

Abstract

Trauma to the genital region and perineum can leave behind lifelong sequelae and pose significant challenges to surgeons in the restoration of functional ability and aesthetic status. Effective methods and techniques are indispensable during the treatment period. Negative pressure wound therapy (NPWT) is a widely accepted technique that is becoming a commonplace treatment in many clinical settings. The purpose of this case report was to introduce the efficacy of the concurrent usage of NPWT and split‐thickness skin grafting (STSG) in the reconstruction of genital injuries. A man suffered a traffic accident that caused necrosis of the scrotum and penis associated with a severe infection caused by Pseudomonas aeruginosa and Enterobacter cloacea. After debridement, we adopted NPWT during the postoperative dressing changes and the application of meshed STSG. The outcomes showed that combination of NPWT and split‐thickness skin grafts is safe, well‐tolerated and efficient in the reconstruction of penoscrotal defects. This could be a versatile tool for reconstruction after perineal and penoscrotal trauma.

Introduction

Trauma to the genital region and perineum may cause lifelong serious physical and psychological sequelae. Regardless of the surgical technique used, reconstruction is often a difficult and complex process. The degree of skin loss and location of the defect are important factors in the selection of the most appropriate treatment option for genitourinary reconstruction. Although effective methods and techniques are available in the reconstruction of perineal and penoscrotal skin loss (1), skin grafting has been reported to be a safe, simple and efficient way to reconstruct scrotal or penile defects (2). The challenging problem that remains for surgeons is the restoration of extensive genital skin loss to its original functional and aesthetic status. For example, the optimal method for fixing the dressings in order to create adequate pressure to improve the take rate of grafts after genital skin grafting is unconfirmed.

Negative pressure wound therapy (NPWT) has become a widely accepted technique that is commonly used in multiple clinical settings (3). It has also been proven to be an effective adjunctive method to compression and fixation (4). In this report, we describe a case in which the combined application of NPWT and meshed split‐thickness skin grafting (STSG) was used to reconstruct severely infected penoscrotal skin loss. Excellent functional and cosmetic outcomes were obtained, as well as a fast recovery.

Case report

A 39‐year‐old man sustained a traffic accident in Jilin province in China and injured his genital region which caused skin avulsion of the scrotum and penis and cystorrhexis on 25th August 2011. He was immediately resuscitated at the scene and admitted to the local hospital, where he underwent repair of the vesical rupture; debridement and suturing of the local skin was performed after careful examination. The skin of the genital region subsequently became necrotic and the patient was transferred to our hospital for definitive treatment of severe perineal skin necrosis and infection on 8th September 2011 (Figure 1). Laboratory examinations were performed, showing that the white blood cell (WBC) was 12·49 × 10⁹/l (neutrophil percentage, 80·61%), and the platelet count was 848 × 10⁹/l, and coagulation tests showed that the fibrinogen degradation product count was 938 mg/dl. Urinary examination showed the following: WBCs 8·30/high power field, red blood cells (RBCs) 41·54/high power field. Cultures of wound swabs from fluid beneath the necrotic skin showed the combined growth of Pseudomonas aeruginosa and Enterobacter cloacea.

Figure 1.

Necrotic scrotum and penis on admission for plastic surgery repair.

Surgical technique

Surgical debridement was performed after the patient was admitted (2, 3, 4). Broad‐spectrum antibiotics were prescribed and dressings were changed every day postoperatively. Three days later, the wound was covered by secretions and necrotic tissue during the dressing change. Therefore, we carried out a hand‐made gauze‐based NPWT based on the same principles as the VAC™ system (KCl Inc., San Antonio, TX) after obtaining written consent from the patient on 12th September 2011. The following are the exact procedures: we prepared 100% cotton gauze, a drainage tube, a drape to close the wound (3M Center, St. Paul, MN) and a suction tube that connected to a vacuum pump on the wall. Then, we made holes on both sides of the drainage tube, the length of which was determined by the size of the wound. We wrapped the drainage tube with some gauze and placed it onto the wound. Finally, we put gauze over both the tube and wound and covered them with the drape, and connected the tube to the suction tube and vacuum pump. Before finishing, the presence of any leakage of the suction tube was assessed. Pressure was applied at −80 mmHg continuously for the duration of therapy. The wound was assessed, photographs were taken and dressings were changed every 2 days. Generally, NPWT devices are well‐tolerated, and no major or minor complications related to use of this device, including pain, maceration and bleeding, were noted.

Figure 2.

There was exposure of both testes and the penis after the initial debridement on admission.

Figure 3.

Internal view of the resection of the infected and necrotic skin.

Figure 4.

Outer view of the resection of the infected and necrotic skin.

STSG was performed on 19th September 2011 (5, 6). We carried out hand‐made gauze‐based NPWT simultaneously (Figure 7).

Figure 5.

Pre‐operative: healthy granulation tissue of the debrided wound was present before proceeding with the reconstruction.

Figure 6.

Intra‐operative photo: a meshed split‐thickness skin grafting is used for coverage of the testicles and a complete skin graft used for the penile shaft.

Figure 7.

Hand‐made gauze‐based negative pressure wound therapy was used simultaneously.

No infection or hematoma occurred postoperatively. The donor site healed well, with no complications or lasting comorbidity. The skin graft survived intact with satisfactory cosmetic and functional outcomes (Figure 8).

Figure 8.

Ten days after placement of meshed split‐thickness skin grafting on the testicles and penis.

Discussion

Advances over recent decades have increased the number of available choices for the treatment of perineal wounds, including free skin grafts 2, 5, flap transplantation (6) and other techniques (1). Currently, it is hardly disputable that autografts are the most commonly used method for the replacement of lost skin (7). However, in many cases it may not be appropriate to close wounds primarily due to the presence or likelihood of infection, or when the wound boundaries are not clear after a degloving injury or a grinding contusion (8). In these cases, dressing change to prepare the wounds to accommodate them for a definitive secondary closure will be exclusively adopted by clinicians.

Instead of simply changing the dressings after infection occurred in our patient, we combined the use of STSG with a hand‐made gauze‐based NPWT for the following reasons. First, it is very difficult to fix dressings to the genital and perineal region during dressing changes or surgery, so this technique enables us to fix the dressing and grafts to avoid displacement or the formation of hematoma or seroma. Second, NPWT has been reported to improve wound conditions by removing necrotic tissue and exudates, which may ultimately increase the success rate of skin graft. Moreover, it can stimulate the proliferation of granulation tissue and improve the microcirculation of the wound (9). Last, the gauze‐based NPWT system we constructed is much cheaper than the commercially available products. These locally available materials for the application of suction to wounds under occlusive dressings may be especially beneficial and useful for uninsured patients and for those in less medically sophisticated countries (10).

This case report bore a resemblance to that published by Shimada et al.(11), in which they introduced their successful experience in the application of a combined negative pressure bolster and free skin graft in a patient with Fournier's gangrene. However, important differences exist between these two cases. First, we did not use denture adherent in our case, as in our experience, the 3M™ Ioban™ 2 Antimicrobial Incise Drape alone can adhere strongly to the wound and surrounding skin to make the enclosed environment airtight, and keep the resulting negative pressure strong enough to compress the skin graft to the wound in order to avoid displacement. In addition, the surgical drape we used contains iodophor‐impregnated adhesive which has continuous antimicrobial activity throughout the procedure. Second, their case reported reconstruction of the lost scrotal skin alone, while we were able to reconstruct the entire denuded scrotum and penis, which inevitably increased the difficulty and complexity of the surgery.

Although some cases have reported that flaps can be used to reconstruct scrotal skin defects 6, 12, 13, three reasons explain why we did not choose such a technique in this case. First, culture results on admission showed infection with P. aeruginosa and E. cloacea. Although the wound was initially dry with no secretions during dressing changes, the surrounding area of the wound still had signs of infection that precluded flap transplantation. Second, a flap may appear tumid and the cosmetic outcome would not have been satisfactory. Third, one of the main functions of the scrotum is to adjust the temperature to ensure that the testes are at a relatively lower temperature than the rest of the body. Wang et al.(14) reported that spermatogenesis, which requires a temperature 2–8° lower than the abdominal environment, is significantly abnormal after 2 years of follow‐up in cases of thick skin flaps and buried testicles. Consequently, if we overlaid the area with a thicker flap, the function of the testes would likely be comprised due to the higher temperature.

No obvious hypertrophic scarring occurred in this current case. This may be related to the short follow‐up duration. Longer term follow‐up is clearly necessary to further understand the functional and cosmetic results.

In conclusion, our experience showed that combined NPWT with STSG in the reconstruction of penoscrotal defect is efficacious and cost‐effective and can act as a ‘bridge’ to enable the wound to undergo an earlier suitable surgical closure and facilitate the recovery of the patient as quickly as possible.