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Necrotising myofasciitis as the initial presentation of a vesico‐urethral anastomotic leak after radical prostatectomy

A 71-year-old man underwent radical retropubic prostatectomy (RRP) and pelvic lymphadenectomy for prostate cancer at a New South Wales metropolitan hospital. Co-morbidities included diabetes, alcohol abuse, chronic obstructive pulmonary disease, aortic valve replacement and coronary artery grafts. His surgery was complicated by dorsal venous complex haemorrhage necessitating activation of a massive transfusion protocol and pelvic packing. He required overnight intensive care unit (ICU) admission for inotropic and ventilatory support. Pelvic packing was removed on postoperative day (POD) four. He was discharged with an indwelling catheter (IDC) on POD eight. Outpatient cystogram on POD 14 demonstrated a vesico-urethral anastomotic leak (VUAL). Repeat cystogram on POD 3 was initially reviewed as normal, but on re-review demonstrated a persistent small VUAL, which was likely missed. He passed a trial of void. On POD 76, he presented to the emergency department of a local district hospital with 3 days’ exacerbation of left thigh pain that commenced shortly after discharge. Clinically, he was in shock with heart rate of 150 beats per minute, blood pressure of 70/60 mmHg, venous blood gas lactate of 10, BE: −8, HCO3: 16. His left thigh was swollen and indurated. Necrotising fasciitis (NF) was diagnosed. He was intubated, commenced on piperacillin-tazobactam, meropenem, vancomycin, clindamycin, inotropes and immediately transferred to our tertiary hospital for surgery. Intra-operatively, extensive necrosis with pus formation of the fascia in most of the muscle compartments of the left thigh from the inguinal ligament to the popliteal fossa was encountered. Debridement included excision of a necrotic gracilis muscle. Scrotal-perineal exam was normal. A VAC (Kinetic Concepts, Inc., San Antonio, TX, USA) dressing was applied, and a relook procedure booked. Serial debridement and washout was performed over the following 4 days. Urine, blood, pus and left thigh tissue cultures all grew pan-sensitive Escherichia coli. Tissue culture also grew Klebsiella pneumoniae. On day seven in ICU, diffuse erythema of the right thigh was noted. A CT scan to look for an abdominal-pelvic aetiology demonstrated extensive inflammatory stranding and swelling of the intermuscular and intra-muscular compartments of both thighs and soft tissues of the perineum with multiple rim enhancing collections and gas bubbles extending to the scrotum and root of the penis. Free fluid adjacent to the bladder raised suspicions of a VUAL. Urologists were consulted. Relook debridement confirmed NF of the right medial thigh, ventral third of the scrotum, and fascia overlying both corpora cavernosa and spongiosum. Debridement of a necrotic section of corpora spongiosum resulted in a urethral defect. A cystogram done the following day confirmed a VUAL. In addition to the IDC, a suprapubic catheter (SPC) was inserted to maximise urinary diversion. Flexible sigmoidoscopy excluded recto-vesical fistula. After three further debridements, his wounds were split skin grafted by the Plastics team with excellent take. He underwent rehabilitation prior to discharge. Follow-up with the urology team at his initial treating hospital was arranged. Necrotising soft tissue infections present as acute or sub-acute necrotising variants of cellulitis, fasciitis or myositis. Fulminant