The effectiveness of negative-pressure wound therapy in the treatment of Fournier’s gangrene – a literature review

Introduction

Hippocrates first described necrotizing soft tissue infections in the 5^th century BC, as a complication of erysipelas [1]. In 1883, Jean Alfred Fournier (1832–1914), a Parisian venereologist reported a syndrome with perineal necrosis in five men [2, 3]. This is a type of necrotising fasciitis, which was named as Fournier’s gangrene (FG) [4, 5].
Furnier’s gangrene is a possibly life-threatening progressive infectious inflammation of the perineal, genital or anal region. It is characterised by thrombosis of blood vessels leading to tissue ischaemia which promotes the progression of infection leading to skin necrosis [6, 7]. The frequency is reported as 1.6 cases per 100,000 men annually and remains stable after the age of 50 (3.3 cases per 100,000 men) [8]. Predisposing factors, such as age, diabetes, alcoholism, malnutrition and immune suppression are often present in affected patients [9, 10]. The incidence of FG is predicted to increase due to the aging demographics and increases in metabolic or immune-related diseases in developed countries. Despite medical developments, the mortality rate of this disease is high as ever. The most effective form of disease management is aggressive debridement and combined antibiotic therapy. Moreover, a vacuum-assisted closure (VAC) dressing can promote wound healing and reduce the chance of reconstructive surgery with skin grafting [11, 12].
Fournier’s gangrene was initially characterized as an idiopathic condition, but recent studies indicate that less than a quarter of FG cases are now classified as idiopathic. Frequently identified causes include colorectal origins (30–50% of cases), urogenital origins (20–40% of cases), skin infections (20% of cases), and localized trauma [13]. Causes related to the colon include local infections, abscesses (especially in perianal, perirectal, and ischiorectal areas), anal fissures, colon perforations, diverticulitis, haemorrhoid surgery, and rectal cancer [14, 15]. Urogenital sources of FG involve urethral narrowing, persistent urinary infections, neurogenic bladder issues, epididymitis, and recent medical procedures. In women, other origins include Bartholin gland or vulvar abscesses, episiotomy, hysterectomy, and septic miscarriage. In children, causes such as insect bites, burns, injury, and circumcision have also been documented [16, 17].
Conventional treatment consists of radical excision of all necrotic tissues, broad-spectrum antibiotics and intensive care. Repeated wound dressing is usually necessary. For this reason, patients’ wounds remain open for a long time and require frequent dressing changes [18]. There are various protocols for postoperative open wound care: untreated honey, hyperbaric oxygenation, growing hormones, growing agents and vacuum dressing technologies. The vacuum-assisted closure device is a wound care system that works by vacuuming under negative pressure, removing exudate and infectious materials, reducing swelling and supporting healing [6]. Many surgeons worldwide have started using negative-pressure wound therapy (NPWT) for fast and effective wound closure. Negative-pressure wound therapy creates an ideal wound healing environment through several mechanisms and it has been a breakthrough in such complex and difficult wounds by creating a faster wound granulation, which is an important aspect of complete wound closure.
A vacuum-assisted closure system uses a sterile, open-cell foam dressing placed within the wound, and its size can be customized to fit the wound dimensions. This foam is sealed with a transparent, adhesive cover to maintain an airtight seal. The foam is attached to a portable vacuum pump through durable tubing that will not collapse. The pump, or sometimes a wall-mounted suction, creates controlled, continuous negative pressure on the foam. By applying both macrostrain and microstrain, this negative pressure environment supports wound healing by exerting mechanical and biological forces that encourage tissue repair. These combined forces help create optimal conditions for wound recovery. The vacuum-assisted closure system accelerates healing by generating micro-tension, which promotes wound closure through fibroblast movement, cell division and growth, while negative pressure reduces swelling and limits fluid accumulation [19, 20].
Vacuum-assisted closure supports faster wound closure, however, applying VAC dressing to the perineal area presents a unique challenge due to its anatomical location and the proximity of the genitals to the anal region. Infectious organisms can spread in the perineum through Colles fascia and extend to the scrotum via dartos fascia. Additionally, the infection can also progress to the abdominal wall through Scarpa’s fascia. During extensive wound debridement in multiple procedures, keeping the wound open is challenging. Properly positioning the VAC dressing and changing it every four days can prevent urinary and faecal contamination. Moreover, it improves well-being due to fewer dressing changes in intimate areas [21, 22].
Fournier’s gangrene involves infections in the genital, perineal, and abdominal regions, with a mortality of 20–40% (if treatment intervention is not provided as soon as possible) [1, 23, 24].

Methods

Data collection

The MEDLINE database was searched on 3 November 2024, and included articles published within the last ten years. The following search query was used: “Fournier gangrene AND negative-pressure wound therapy” with one filter “free full text”. Ten independent researchers screened results. The initial search returned 38 results. After screening of abstracts, 28 results were chosen for full text analysis, 6 of which met inclusion criteria and were included in the study. A flowchart of study inclusion is presented in Figure 1.

Inclusion and exclusion criteria

Studies were included into analysis if predefined patients, interventions, comparisons, outcomes (PICO) criteria were met (Table 1). The research was funded by the authors.

Selection criteria

A flowchart of study inclusion is presented in Figure 1.

Inclusion and exclusion criteria

Studies were included into analysis if predefined PICO criteria were met (Table 1)

Quality assessment

This review was performed according to PICO guidelines.

Results

Characteristics of studies

This section provides a detailed overview of the six studies analysed in this review, as presented in Table 2. Each study evaluates the efficacy of NPWT using VAC compared to conventional dressings in the treatment of FG. The general consensus across the studies suggests that VAC therapy is a beneficial adjunct to standard FG treatment, particularly in reducing wound healing time. However, differences in study design, patient selection, and methodology contribute to variability in reported outcomes.

Study descriptions

Yanaral et al. analysed 54 patients, with 31 treated using conventional dressings and 23 with VAC therapy. The mean hospital stay was 14 days in the conventional dressing group and 17 days in the VAC group. The time from initial surgical debridement to wound closure was 12 days for conventional dressings and 13 days for VAC therapy.
The study found no significant difference in hospitalization duration, but VAC therapy resulted in slightly faster wound healing.
A strength of this study is its clear comparison of hospitalization time and wound closure time between the two treatment groups. However, its relatively small sample size and lack of analysis regarding comorbidities may limit the generalizability of the results [6]. Tanwar et al. examined 84 patients, evenly divided between conventional dressings and VAC therapy. The average hospitalization time was 11.36 days in the conventional dressing group and 8.14 days in the VAC group. The time from surgical debridement to wound closure was significantly shorter in the VAC group, averaging 63 days, compared to 112.56 days for conventional dressings.
These findings suggest that VAC therapy significantly accelerates wound healing.
The major strength of this study is its larger sample size compared to others, allowing for more robust statistical analysis. However, it does not account for potential confounding factors such as variations in surgical technique or differences in wound severity, which may have influenced the results [1].
Michalczyk et al. studied 35 patients, with 22 receiving conventional dressings and 13 treated with VAC therapy. The average hospitalization time was 23 days for conventional dressings and 26 days for VAC therapy.
The study did not provide data on the time to wound closure, which limits its ability to assess the full effectiveness of VAC therapy. While the study offers valuable insights into hospitalization duration, the lack of wound closure data is a significant limitation. Additionally, the small sample size and absence of long-term follow-up data reduce the strength of the conclusions [25].
He et al. analysed 36 patients, with 9 treated using conventional dressings and 27 with VAC therapy. The study found that the average hospitalization time was significantly longer in the conventional dressing group at 51 days, compared to 38 days for the VAC group. The time from initial surgical debridement to wound closure was also shorter in the VAC group, averaging 39.2 days compared to 66.5 days in the conventional dressing group.
The study concluded that VAC therapy led to faster wound healing and reduced hospitalization time.
A key strength of this study is its clear demonstration of VAC therapy’s benefits in wound closure time and hospitalization duration. However, the small number of patients in the conventional dressing group (n = 9) limits the comparability between the two treatment methods [8].
Chen et al. included 36 patients, with 10 receiving conventional dressings and 26 treated with VAC therapy. The average hospitalization time was 19.6 days for conventional dressings and 31.69 days for VAC therapy. The time from initial surgical debridement to wound closure was 33.6 days in the conventional dressing group and 39.6 days in the VAC group.
These findings suggest that while VAC therapy resulted in a longer hospital stay, its impact on wound closure time was less pronounced compared to other studies.
A strength of this study is its balanced comparison of both treatment methods within a well-defined patient cohort. However, the significantly longer hospitalization time in the VAC group raises questions about possible confounding factors, such as differences in wound severity or patient comorbidities, which were not thoroughly analysed in the study [26].
Iacovelli et al. investigated 62 patients, with 43 treated using conventional dressings and 19 with VAC therapy. The study found that the average hospitalization time was 18 days in the conventional dressing group and 28 days in the VAC group. The time from surgical debridement to wound closure was 23 days for conventional dressings and 45 days for VAC therapy.
This study further confirmed the efficacy of VAC therapy in facilitating wound healing, however, the prolonged hospitalization duration observed in the VAC group suggests that additional clinical factors, such as patient comorbidities or postoperative complications, may have influenced the length of stay.
A strength of this study is its relatively larger sample size compared to others included in this review, providing more robust data on treatment outcomes. However, the significant difference in sample size between the two groups (43 vs. 19) may introduce bias in the analysis. Additionally, the study does not specify whether differences in patient conditions, wound severity, or postoperative care protocols contributed to the observed variations in hospitalization duration [27].
Across all studies, NPWT using VAC therapy demonstrated superior efficacy in reducing wound healing time compared to conventional dressings. The aggregated data are presented in Figure 2. The application of NPWT was associated with enhanced wound granulation, improved exudate management, and decreased need for frequent dressing changes, contributing to greater patient comfort. However, some studies reported longer wound closure times in the VAC group, highlighting variability in treatment response based on patient characteristics and wound severity. Additionally, challenges in the application of VAC therapy in the perineal and genital regions were noted due to anatomical constraints and potential contamination risks.
Hospitalization duration varied among studies, with some reporting longer stays for VAC therapy, particularly in cases where patient complexity, postoperative complications, or treatment monitoring requirements may have influenced outcomes. The aggregated data are presented in Figure 3. While VAC therapy was consistently associated with faster wound closure, its impact on overall hospitalization time was less uniform, with certain studies indicating a prolonged length of stay in VAC-treated patients. The primary strengths of these studies include their direct comparisons of VAC therapy and conventional dressings, as well as their contributions to understanding NPWT’s role in FG management. However, key weaknesses include small sample sizes, significant disparities in group sizes within some studies, and insufficient control for confounding factors such as comorbidities, wound severity, and variations in postoperative care protocols.
While NPWT showed clear advantages in wound closure time, its higher cost and the requirement for specialized medical supervision were highlighted as potential limitations. Future research should further investigate long-term outcomes, cost-effectiveness, and patient-reported quality of life measures. Additionally, standardized treatment protocols and larger, multicentre trials are needed to better define the role of VAC therapy in FG management and to optimize patient selection criteria for this intervention.

Analysis

The total number of all patients is 307.
157 patients were treated with conventional dressings and 150 patients with VAC.
The average hospitalization time for the group with conventional dressings is 22.8 days, while for the group with VAC therapy it is 24.8 days.
The average time from initial surgical debridement to wound closure for conventional dressings is 49.5 days while for VAC it is 40 days.

Discussion

In the study The role of vacuum assisted closure (VAC) therapy in the management of Fournier’s gangrene, two groups of patients were considered. The first included local wounds, and the second group included disseminated wounds. In the rest of the articles, only local wounds were included, so I excluded the group of disseminated wounds [27].
This study focused on hospitalization time and wound closure time. However, this comparison does not take into consideration predisposing factors in patients, such as diabetes, alcohol abuse, immunodeficiency, malignancies, and liver and kidney disease. The presence of these comorbidities is associated with a poorer prognosis and higher mortality. The most common coexisting disease in patients with necrotizing enterocolitis is diabetes mellitus (10–60%). Fournier’s gangrene can result from surgical wounds, pressure injuries, skin tissue drainage, and decubitus ulcers. It can also occur as a complication of cancer associated with bowel injury, rectal and anal wounds, and bowel perforation [6].
Furthermore, the comparison does not account for the advantages of VAC dressing, which is an effective method of reducing the number of dressing changes, minimizing pain, and increasing mobility compared to conventional dressing [1]. However, NPWT has limitations. It cannot replace surgical wound debridement as a primary wound treatment technique as inappropriate use can exacerbate infection [8]. Additionally, VAC therapy has been criticized for its high cost, which can limit its accessibility [27].
Despite advancements in diagnostic and treatment techniques, mortality from FG remains high. The two main factors that have a direct impact on mortality are early and accurate surgical debridement of the wound and the initial stage of the disease at diagnosis [26].
Our study showed that the average hospitalization time was shorter for patients treated with conventional dressings than for those treated with VAC therapy. In contrast, the average time from initial surgical debridement to wound closure was shorter for the VAC method than for conventional dressings. These findings suggest that while conventional dressings may allow for earlier hospital discharge, VAC therapy can accelerate the wound healing process.

Implications for practice

From a clinical perspective, the choice between VAC therapy and conventional dressings should be tailored to the patient’s overall condition, wound severity, and healthcare resources. Vacuum-assisted closure therapy offers benefits such as reduced pain, fewer dressing changes, and greater mobility, which enhance patient comfort and well-being. However, its higher cost and the necessity for careful monitoring to prevent infection should be considered when making treatment decisions.

Strengths and weaknesses of the study

A strength of this study is its direct comparison of VAC therapy and conventional dressings in patients with Fournier’s gangrene, providing insights into the impact of both methods on hospitalization and wound healing time. However, a significant limitation is the exclusion of patient comorbidities and predisposing factors, which can influence treatment outcomes. Additionally, the study does not evaluate long-term complications, patient satisfaction, or cost-effectiveness in a broader healthcare context.

Potential limitations

The retrospective design of this study and the relatively small sample size may limit the generalizability of the findings. Additionally, variability in surgical techniques, treatment adherence, and healthcare provider expertise could have introduced potential biases. The exclusion of patient comorbidities and predisposing factors, along with heterogeneity in treatment protocols, should also be considered when interpreting the results.
Future research should prioritize larger, multi-centre cohorts, long-term patient outcomes, and cost-effectiveness analyses to provide a more comprehensive evaluation of these therapeutic approaches. Furthermore, randomized controlled trials incorporating a rigorous assessment of patient-specific factors are warranted to enhance the validity and clinical applicability of these findings.

Conclusions

Our study demonstrated that while conventional dressings resulted in a shorter average hospitalization time, VAC therapy accelerated the wound healing process by reducing the time from initial surgical debridement to wound closure. Despite these findings, it is not possible to determine a clear superiority of one method over the other.
From a clinical standpoint, the choice of treatment should be individualized based on patient condition, wound severity, and healthcare resources. VAC therapy offers advantages such as reduced pain, fewer dressing changes, and increased mobility, leading to improved patient comfort. However, it is associated with higher costs and requires careful monitoring to prevent complications.
Future studies should further investigate patient-centred outcomes, cost-effectiveness, and long-term healing rates to provide a more comprehensive assessment of these treatment approaches.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References