BERKELEY, CA (UroToday Inc.) - Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. It is usually characterized by a rapidly progressive course of infection that tracks along the fascial planes of the perineum. Many have advocated the routine use of adjuvant hyperbaric oxygen (HBO) therapy in the treatment of this disorder. Hyperbaric oxygen has been shown to increase oxygen tension in infected tissues with the goal to aid in the fight against anaerobic organisms and to improve wound healing.

A recent review by S. R. Mindrup and colleagues from the University of Iowa examined whether the use of HBO in the treatment of Fournier's gangrene led to improvements in morbidity, mortality and costs associated with treating this disease. The review is published in the June, 2005 issue of the Journal of Urology.

In the study, records from 42 patients treated for Fournier's gangrene over a 9 year period were reviewed. Patients were followed for a mean of 4.2 years. Of the patients 16 were treated with surgical debridement and antibiotic therapy alone, and 26 were treated with HBO (a median of 6 treatments) and debridement and antibiotics. The decision to initiate HBO was nonrandomized and at the discretion of the attending surgeon.

Hyperbaric oxygen therapy typically involves treatment immediately post-operatively, and transporting and monitoring these severely ill patients in this setting can be difficult. The cost of HBO is also not trivial with the average treatment cost being between $600 and $1,300. Analysis showed that the disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of the nonHBO group and in 19% of the HBO cases. The skin graft failure rate was 6% for nonHBO and 8% in the HBO group. The hospital costs per day were also greater in the HBO group ($3,384 vs. $2,252).

The major flaw in this study is its retrospective design. The results suggest that HBO treatment may have been reserved for more ill patients. The ultimate answer to the question as to whether there is clinical benefit of HBO in Fournier's gangrene will need to be answered in a prospective, multicenter trial. Until this trial is performed, the authors believe that the routine use of HBO should not be recommended, and that the mainstay of treatment for this disorder needs to continue to be wide, adequate, initial debridement, followed by meticulous fluid and metabolic management. The authors currently reserve HBO as adjuvant therapy for only the most severe cases.

J Urol. 2005 Jun; 173(6):1975-7