Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95(3):11450 1 ORIGINAL PAPER and is usually caused by an aerobic bacterial invasion (1). The bacterial species' combined invasive and toxic activi- ties produce endarteritis obliterans, cutaneous and subcu- taneous artery thrombosis, local tissue necrosis and gan- grene, and subsequently life-threatening adverse events such as multiple organ system failures, septic shock, and death if left untreated (1, 2). Despite the advancement of medical knowledge towards FG’s pathobiology, diagnosis, and management, the mor- tality rate remains high, with some reported rates of approximately 50% (3). FG is a predominantly male ill- ness and is commonly observed in men aged 40 to 50, with a reported annual incidence of 1.6 cases per 100.000 men. Diabetes mellitus (DM), older age, liver cirrhosis, vas- cular disease, cancer, chronic alcoholism, overweight, paraplegia, and renal impairment are all thought to be associated with higher mortality rates; however, up to 30% to 50% of FG cases present with no identifiable risk fact (4). There are numerous scoring methods for predict- ing FG mortality, such as the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, which is an extensively used tool for predicting mortality outcomes, Charlson Comorbidity Index (CCI), and Fournier's Gangrene Severity Index (FGSI) which are well-defined disease-spe- cific metric (5, 6). However, those scorings still had limi- tations and some factors are not included such as length of hospital stay, which is related to hospitalization costs and treatment approaches (4). In low-income countries, such as Yemen, there is limited information available about the extent of FG mortality rate, and its predisposing factors (7). Here, we studied the characteristics and clinical course of patients diag- nosed with FG at our institution over a period of 12 years. Our primary objective was to discern the prog- nostic factors intricately linked to this debilitating dis- ease. By furnishing essential data, we aspire to enhance the foundation for future investigations and therapeutic interventions. Such endeavors hold immense potential to empower healthcare practitioners in promptly identify- ing FG and initiating timely and efficacious care for afflicted individuals. Background: Fournier’s gangrene (FG) is a destructive necrotizing infection with a gen- erally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identi- fy prognostic factors for FG mortality. Methods: A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality. Result: The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG. Conclusions: Fournier’s gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart fail- ure, cerebrovascular accident, liver cirrhosis, presence of multi- ple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality. KEY WORDS: Fournier's gangrene; Mortality; Prognostic factors; Outcome. Submitted 5 May 2023; Accepted 8 June 2023 INTRODUCTION Fournier's gangrene (FG) is a poly-microbial necrotizing infection that spread drastically to involve the genital, perianal area, or perineal deep tissue causing rapid tissue Prognostic determinants and treatment outcomes of Fournier’s Gangrene treatment in a resource-limited setting: A retrospective study Saif Ghabisha 1, Faisal Ahmed 2*, Saleh Al-wageeh 1, Mohamed Badheeb 3, Qasem Alyhari 1, Abdulfattah Altam 4, Afaf Alsharif 5 1 Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen; 2 Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen; 3 Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, USA; 4 Department of General Surgery, School of Medicine, 21 September University, Sana'a, Yemen; 5 Department of Gynaecology, School of Medicine, Jeblah University for Medical and Health Sciences, Ibb, Yemen. DOI: 10.4081/aiua.2023.11450 Summary Archivio Italiano di Urologia e Andrologia 2023; 95(3):11450 Saif Ghabisha, Faisal Ahmed, Saleh Al-wageeh, Mohamed Badheeb, Qasem Alyhari, Abdulfattah Altam, Afaf Alsharif 2 MATERIALS AND METHODS Study design Between Jun 2010 to Oct 2022, this retrospective study was conducted at Ibb University-affiliated Hospitals and included 36 consecutive patients diagnosed with FG and treated by the same surgeon (Professor S. Ghabisha). The Ethics Research Committees of Ibb University provided their approval for the study (ID: IBBUNI.AC.YEM.2023.55, on 03.03.2023), which adhered to the ethical principles out- lined in the Declaration of Helsinki. Inclusion criteria Patients diagnosed with FG and treated at Ibb University- affiliated hospitals (Al-Nasar Hospital) were included in the study. The presence of fever (> 38°C), erythema and swelling in the perianal or scrotal region, purulent-mal- odorous discharge, and the detection of fluctuation or crepitation at the wound site were used to make the diag- nosis of FG (8). Exclusion criteria Patients treated at other hospitals and those with scrotal, periurethral, or perianal abscesses with no fascial or soft tissue extension were excluded. Surgical procedure and postoperative care All participants received immediate aggressive debride- ment under general or spinal anesthesia to remove necrotic tissue until healthy tissue was observed. In addi- tion, cystostomy catheters were placed, limiting the con- tact of the urethra with urine. Empiric intravenous antibi- otic therapy, including crystalline penicillin (4miu IV every 6 hours), ceftriaxone (1 g every 12 hours), and metronidazole (500 mg every 12 hours), was adminis- tered until culture results were obtained and in cases of sepsis, imipenem and vancomycin were used. Dressings were changed three times daily with sterile gauze soaked in a solution of povidone-iodine, 0.2% nitrofurazone ointment, and 250 mg rifampicin ampoule and hyperbar- ic oxygen was done in cases needing multiple debride- ments (9). A fecal diversion (colostomy) was performed in cases where the perirectal and anal regions were affect- ed, while an orchiectomy was performed in testicular involvement cases (5). Patients were transferred to the Plastic and Reconstructive Surgery Clinic once their general health status and wound cleanliness had improved. Data collection Patient demographic characteristics, including age, time to hospital admission, comorbidities, albumin level, number of surgical debridements, need for mechanical ventilation, need for colostomy diversion or orchiectomy, length of hospital stay, and mortality were extracted from the patient's medical records. Mortality refers to all-cause mortality and any cause of FG-related death during the initial admission or follow-up. To assess the FG extension, we used a modified body surface area nomogram com- monly used for estimating the extension of burn injuries. This involved assigning a value of 1% for penile, scrotal, and perineal involvement, and 2.5% for ischiorectal fossa involvement (5, 8). The comorbidities were heart failure, end-stage renal disease (ESRD), liver cirrhosis, history of anorectal surgery, and old cerebrovascular accident (CVA), which were also evalu- ated as several comorbidities (presence of one versus more than one of comorbidities) (10). The number of surgical debridements was defined as the number of times a patient entered the operating room (10). The albumin level was dived into two categories (equal or more than 3 g/dL and less than 3 g/dL). Variables and measures The outcome variable was FG mortality expressed as a binary variable: alive and dead. Independent variables included age (≤ 65 years and more than 65 years), CVA (yes and no), heart disease (yes and no), liver cirrhosis (yes and no), ESRD (yes and no), the number of debride- ment (≤ 2 times and ≥ times), comorbidity number (one and more than one), need for a colostomy (yes and no), need for orchiectomy (yes and no), mean hospital stays, etiological subtypes (genitourinary infection versus non- genitourinary infections), septic condition (yes and no), comorbidity number (< two comorbidities and ≥ two comorbidities), mean total affected body surface area (≤ than 3% and more than 3%), blood urea nitrogen Figure 1. A. Fournier’s gangrene involved the scrotum. B. Fournier’s gangrene involved the penis, scrotum, and ischiorectal fossa. C. Fournier’s gangrene involved both the penis and scrotum with a purulent discharger. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11450 3 Fournier's Gangrene outcome (BUN) (more than 50 mg/dl and less), Albumin level (≤ 3 g/dL and more than 3 g/dL), need for mechanical ventila- tion (yes and no), time to hospital presentation (≤ 7 days and more than 7 days), and DM (yes and no). Study outcome The mortality rate and the independent predictors of FG mortality. Statistical analysis The study utilized both quantitative and qualitative, for which means and standard deviations were used to present quantitative data, while frequencies and percentages were reported for qualitative variables. The normality of the data was confirmed using the Smirnov-Kolmogorov test. To determine the independent risk variables related to FG mortality, univariate analysis was done. Effect sizes in the model were expressed using odds ratios and confidence intervals at 59%. The statistical significance level was set at p < 0.05. The IBM SPSS version 22 software (IBM Corp., Armonk, New York) was used for statistical analysis. RESULT Baseline clinical characteristics The mean age was 68.30 ± 5.61 years and most of patients (69.4%) were aged more than 65 years. The main time to hospital presentations was 7.47 ± 4.10 days and 15 (41.7%) patients presented after 7 days from starting symptoms. Most of them (25, 69.4%) were in septic conditions. History of DM, heart failure, ESRD, CVA, anorectal sur- gery, and liver cirrhosis was present in 20 (55.6%), 11(30.6%), 8 (22.2%), 5(13.9%), 6 (16.7%), 6 (16.7%), respectively. Additionally, 14 (38.9%) had more than one comorbid number. The source of infection was a geni- tourinary infection in 15 (41.7%) patients, perianal infec- tion in 6 (16.7%) patients, and an unknown source in 15 (41.7%) patients. The mean calculated total affected body surface area was 3.59 ± 1.47 (%) and was more than 3% in (19, 52.8%) patients. The serum albumin level was less than 3 g/dL in 14 (38.9%) patients. Most of the patients (72.2%) more than one surgical debridement. Colostomy and orchiectomy were done on 6 (16.7%) and 3 (8.3%) patients respectively. The mean hospital stay was 57.00 ± 4.01 days and 15 (41.7%) patients need mechanical venti- lation. Within a median follow-up time of 14.0 months (range 2-30 months), 23(63.9%) of patients survived and the total mortality rate was 36.1%. Table 1 summarizes the baseline clinical characteristics of the research cohort. Mortality predictors in patients with Fournier’s gangrene The association of independent variables with the dependent vari- able was investigated using uni- variate, analysis. Univariate analy- sis showed that advanced age (p = 0.02), delayed in hospi- tal presentation (p = 0.024), involvement of larger area (p = 0.001) (Table 2), a history of DM (p < 0.006), ESRD (p = 0.018), heart failure (p = 0.005), CVA (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidi- ties (p = 0.001), septic conditions at admission (p = 0.048), (p = 0.018), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mor- Table 1. Demographic characteristics of patients. Variable Subgroup N (%) Age (year) Mean ± SD 68.30 ± 5.61 < 65 years 11 (30.6) ≥ 65 years 25 (69.4) Time to hospital admission (days) Mean ± SD 7.47 ± 4.10 (2-20) ≤ 7 days 21 (58.3) > 7 days 15 (41.7) Source of infection Urinary tract infection 15 (41.7) Perianal or perirectal infection 6 (16.7) Unknown 15 (41.7) Septic condition - 25 (69.4) Predisposing factors Diabetes mellitus 20 (55.6) Heart failure 11 (30.6) Renal failure 8 (22.2) Cerebrovascular accident 5 (13.9) Liver cirrhosis 6 (16.7) Anorectal surgery 6 (16.7) Comorbid number One 22 (61.1) ≥ Two 14 (38.9) Total affected body surface area (%) Mean ± SD 3.59 ± 1.47 ≤ 3% 17 (47.2) > 3% 19 (52.8) Number of debridement Mean ± SD 2.27 ± 1.13 (1-5) One 10 (27.8) ≥ Two 26 (72.2) Needs for colostomy - 6 (16.7) Needs for orchiectomy - 3 (8.3) Need for mechanical ventilation - 15 (41.7) Blood urea nitrogen (mg/dl) ≥ 50 18 (50) Albumin level (mg/dl) < 3 14 (38.9) Hospital stay (day) Mean ± SD 7.00 ± 4.01 Outcome Survivors 23 (63.9) Non-survivors 13 (36.1) Table 2. Comparison between survivors and survivors for quantitative variables. Variable Outcome Mean difference (95 % CI) t & z P-value * Survivors N = 23 Died N = 13 Mean (SD) Mean (SD) Age (year) 66.69 (5.19) 71.15 (5.35) -4.45(-8.15 to -0.75) -2.44 0.020 Number of debridements 2.21(1.12) 2.38(1.19) -0.16(-0.97 to 0.64) -0.42 0.678 Time to hospital presentation (days) 6.91 (4.83) 8.46(2.14) -1.54(-4.43 to 1.33) -1.09 0.024 Total BSA (%) 3.00(1.47) 4.65(0.65) -1.65(-2.53 to -0.77) -3.81 0.001 Hospital stay (days) 7.08 (3.42) 6.84(5.04) 0.24(-2.63 to 3.11) 0.170 0.361 BSA: Body surface area. * P-values of < 0.05 were considered significant. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11450 Saif Ghabisha, Faisal Ahmed, Saleh Al-wageeh, Mohamed Badheeb, Qasem Alyhari, Abdulfattah Altam, Afaf Alsharif 4 tality in patients with FG (Table 3). The relative risk of SSI occurrence was also higher among patients with genitouri- nary infection; however, it was not statistically significant in univariate analysis (p = 0.075). DISCUSSION In this study, we evaluated the predictive factor for mor- tality in FG patients who were treated in resource-limited settings. The survival rate was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age, delayed in hospital presentation, involvement of larg- er area, a history of DM, ESRD, heart failure, CVA, liver cirrhosis, presence of multiple comorbidities, septic con- ditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were found to be risk factors for mortality in patients with FG. FG is a polymicrobial illness that resulted typically from facultative aerobic and anaerobic bacterial growth. The rapid proliferation is linked to decreased cellular immuni- ty of FG’s patients and the synergistic release of toxins (11). The mortality associated with the disease is high and has been reported from 6% to as high as 76% (12). In this study, the total mortality rate was 36.1%. This is in agreement with other studies in most developing countries. For example, Sabzi et al. study in Iran reported a mortality rate of 37.5% (12). In our study, genitourinary infec- tion was the most common cause of FG and one-third of cases had an unknown etiology. Our result was similar to Tahmaz et al.'s study, which reported that 33% of FG cases were due to genitouri- nary infections (13). Nevertheless, no identifiable cause was observed in one-quarter of the patients in the El-Qushayri et al. study (14). The factors that predict FG mor- tality are, for the most part, debat- able. Because many studies are retrospective and included a small number of patients. For that, solid criteria are still missing and statis- tical analysis is still limited. There is a discrepancy in the literature regarding several independent prognostic factors in patients with FG. For example, some studies have shown that younger age was associated with improved survival (8, 15, 16). While other studies have not found a significant dif- ference in disease onset between various age groups (17, 18). In our study group, advanced age was noticed among non-surviving patients and was a risk factor for FG mortality in univariate analysis. In line with earlier research, the majority of our patient population had DM as the most common comorbidity. This pathology in our study was a predictive factor for mortality in univariate analysis (19, 20). According to pre- vious researchers, the incidence of DM was found in between 50% and 70% of FG patients (19, 21). DM has been identified as a risk factor for FG and has been linked to a more progressive and poorer outcome due to reduced phagocytic and intracellular bactericidal activity and neu- trophil dysfunction (19). Certain conditions such as alcohol consumption, immuno- compromised status, malignancy, heart failure, hepatic dis- ease, and ESRD were reported to be associated with FG mortality (8, 13, 22). Similarly, in our study, those factors were associated with FG mortality and were statistically significant in univariate analysis. Additionally, 38.9% of our patients had at least one of the following conditions: ESRD, cardiac insufficiency, CVA, and liver cirrhosis; these conditions were highly repre- sented among nonsurvivors patients. In Roghmann et al. Table 3. Comparison between survivors and non-survivors for categorical variables. Variable Sub Total (n = 36) Outcome Univariate analysis variable N (%) Survivors N (%) Died N (%) OR (95 % CI) P-value * Age (year) < 65 11 (30.6) 9 (81.8) 2 (18.2) 0.28 (0.05 to 1.58) 0.151 ≥ 65 25 (69.4) 14 (56.0) 11 (44.0) Reference group Diabetes mellitus Yes 20 (55.6) 8 (40.0) 12 (60.0) 22.50 (2.46 to 205.7) 0.006 No 16 (44.4) 15 (93.8) 1 (6.3) Reference group Number of debridements ≤ 1 10 (27.8) 6 (60.0) 4 (40.0) 1.25 (0.28 to 5.65) 0.763 > 2 26 (72.2) 17 (65.4) 9 (34.6) Reference group Time to the presentation (day) ≤ 7 21 (58.3) 16 (76.2) 5 (23.8) 0.27 (0.06 to 1.14) 0.075 > 7 15 (41.7) 7 (46.7) 8 (53.3) Reference group Comorbidity number ≤ 1 22 (61.1) 19 (86.4) 3 (13.6) 0.06 (0.01 to 0.33) 0.001 > 1 14 (38.9) 4 (28.6) 10 (71.4) Reference group Need colostomy Yes 6 (16.7) 4 (66.7) 2 (33.3) 0.86 (0.13 to 5.50) 0.877 No 30 (83.3) 19 (63.3) 11 (36.7) Reference group Need orchiectomy Yes 8 (8.3) 2 (66.7) 1 (33.3) 0.87 (0.07 to 10.69) 0.917 No 33 (91.7) 21 (63.6) 12 (36.4) Reference group Septic condition Yes 25 (69.4) 13 (52.0) 10 (90.9) 9.23 (1.02 to 83.33) 0.048 No 11 (30.6) 1 (9.1) Reference group CVA Yes 0 (0.0) 0 (0.0) 5 (100.0) - 0.003 No 0 (0.0) 23 (74.2) 8 (25.8) Reference group Liver cirrhosis Yes 0 (0.0) 6 (100.0) - 0.001 No 23 (76.7) 7 (23.3) Reference group History of heart failure Yes 11 (30.6) 3 (27.3) 8 (72.7) 10.66 (2.04 to 55.51) 0.005 No 25 (69.4) 20 (80.0) 5 (20.0) Reference group ESRD Yes 8 (22.2) 2 (25.0) 6 (75.0) 9.00 (1.46 to 55.24) 0.018 No 28 (77.8) 21 (75.0) 7 (25.0) Reference group History of anal surgery Yes 6 (16.7) 4 (66.7) 2 (33.3) 0.86 (0.13 to 5.50) 0.877 No 30 (83.3) 19 (63.3) 11 (36.7) Reference group Mechanical ventilation Yes 15 (41.7) 4 (26.7) 11 (73.3) 26.12 (4.09 to 166.0) 0.001 No 21 (58.3) 19 (90.5) 2 (9.5) Reference group Etiology Non-GU 21 (58.3) 16 (76.2) 5 (23.8) 0.27 (0.06 to 1.14) 0.075 GU 15 (41.7) 7 (46.7) 8 (53.3) Reference group BUN (mg/dl) < 50 18 (50.0) 17 (94.4) 1 (5.6) 0.03 (0.003 to 0.27) 0.002 ≥ 50 18 (50.0) 6 (33.3) 12 (66.7) Reference group Albumin (g/dL) < 3 22 (61.1) 2 (14.3) 12 (85.7) 126.0 (10.31 to 1539) < 0.001 ≥ 3 14 (38.9) 21 (95.5) 1 (4.5) Reference group BSA: body surface area; BUN: Blood urea nitrogen; CI: confidence interval; CVA: cerebrovascular accident; ESRD. End-Stage Renal Disease; GU: Genitourinary; OR: odds ratio. * P-values of < 0.05 were considered significant. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11450 5 Fournier's Gangrene outcome study, history of DM, ESRD, cardiac insufficiency, CVA, liver cirrhosis, and comorbidity were outcome predictors and Authors suggested that the presence of multiple comorbidities might predict poorer outcomes (23). In our study, the presence of multiple comorbidities was associ- ated with FG mortality in univariate analysis. The duration between symptom onset and treatment ini- tiation has been reported as a significant predictor of out- comes for patients with FG (19, 24). However, these find- ings are not universally agreed upon. For instance, a study by Sallami et al. reported no significant difference in time to admission between survivors and non-survivors (20). In our study, we found that a longer time to hospi- tal admission was significantly associated with FG mor- tality (p = 0.024). Other reports mentioned higher mor- tality among FG patients with delayed hospital admission (19, 24). These inconsistencies may be attributed to vari- ations in study settings, patient demographics, hospital accessibility, income, and educational levels. In our study, the delayed patient presentation may be attributed to the limited access to healthcare facilities. Specifically, the residence of our cohort was located at a considerably far distance from the specalized health centers, from the study area, which likely contributed to the delay in seek- ing medical attention. Various laboratory abnormalities have been evaluated to predict FG mortality, including white blood cell (WBC) count, blood urea nitrogen (BUN), serum creatinine, albu- min, calcium, and sodium (12, 23). However, there is a discrepancy in the literature regarding several independ- ent laboratory prognostic factors in patients with FG. Sabzi Sarvestani et al. reported a significant correlation between those factors and FG mortality (12). These find- ings were also endorsed by Yeniyol et al., who showed ele- vated WBC, BUN, creatinine, alkaline phosphatase (ALP), and lactate dehydrogenase levels, and lower hematocrit, metabolic acidosis, hyponatremia, hypokalemia, in addi- tion to decreased total protein, and albumin levels in non survivors compared to survivors (17). Reduced sodium levels, along with lower serum albumin and total protein levels, can signify both a catabolic state and a poor response to therapy, which were seen among these patients with a worse prognosis and higher mortality rates. These factors are directly correlated with poor out- comes (20). Laor et al. found a higher level of calcium, albumin, and cholesterol, and lower levels of BUN and ALP at admission of surviving patients compared to non- survivors (25). Another retrospective study, reported that BUN > 50 mg/dL was significantly associated with a high- er mortality (26). It should be noted that various con- founding factors or effect modifiers (e.g., severe dehydra- tion, sepsis, and shock) that were not controlled in the study may have influenced these findings. Our univariate analysis showed that albumin levels lower than 3 g/dL and BUN > 50 mg/dL were associated with overall increased mortality. Nevertheless, the generalizability of these findings is limited by the small and heterogeneous nature of our cohort. The reported indications for orchidectomy in FG patients were preexisting epididymorchitis, gangrenous testis dam- age, or scrotal abscess (21). Although testicular involve- ment appears to be uncommon in FG, a modest incidence rate was reported by Sallami et al. as seven patients, of 40 included, underwent orchidectomy for gangrenous testis damage; in addition to four patients needed subcutaneous testicular repositioning (20). In our study, three patients underwent orchidectomy as a sequala of testicular gan- grenous necrosis. A colostomy is sometimes needed to decrease fecal contamination, especially in the presence of infective sphincteric destruction or rectal perforation (20, 27). In our study, six patients underwent colostomy diver- sion due to the extensively involved perianal area. This study found a significant difference in the average extent of body surface area affected by necrotizing tissue between patients who survived and those who did not (3.0 ± 1.5 vs. 4.7 ± 0.7 respectively). The number of sur- gical debridements, on the other hand, did not have a sig- nificant impact on patient outcomes, which is in line with the findings of Yeniyol et al. (17). However, the result reported by Spirnak et al. differs from these findings, as they showed a higher mortality rate among patients who underwent more frequent debridements due to more extensive disease (28). Generally, prompt surgical intervention (aggressive and often repeat debridement), broad-spectrum antibiotics, and appropriate resuscitation are crucial in these patients (29). As expected, patients with large involved body sur- face areas usually died during the hospital course, and the chance of undergoing multiple debridements subse- quently decreased in this group. A similar report has been mentioned by Sabzi Sarvestani et al. (12). Postoperative mechanical ventilation has been demon- strated as a powerful factor in FG mortality. In Benjelloun et al. and Yanar et al. studies, the need for mechanical ventilation is a predictive factor for FG mortality (30, 31). Our findings are consistent with those previously report- ed in the literature and the need for mechanical ventila- tion was an independent predictor of mortality (30, 31). This study has several limitations. Firstly, the retrospec- tive design and the small sample size were potential sources of bias that might limit the generalizability of our findings. Secondly, due to the nature of the study, some relevant factors, such as blood gas analysis data, APACHE II scoring system, CCI, and FGSI, were not included in our analysis. Future studies with more sample sizes and prospective designs are recommended to strengthen the validity and generalizability of our findings. CONCLUSIONS FG represents a critical medical condition with notable morbidity and mortality rates. In this study, Advanced age, delayed in hospital presentation, involvement of larger area, a history of DM, ESRD, heart failure, CVA, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality. ACKNOWLEDGMENTS The authors would like to thank the general manager of Al-Thora General Hospital and Al-Nassar Hospital, Ibb, Yemen, Dr. Abdulghani Ghabisha, for editorial assistance. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11450 Saif Ghabisha, Faisal Ahmed, Saleh Al-wageeh, Mohamed Badheeb, Qasem Alyhari, Abdulfattah Altam, Afaf Alsharif 6 REFERENCES 1. Boughanmi F, Ennaceur F, Korbi I, et al. Fournier's gangrene: its management remains a challenge. Pan Afr Med J. 2021; 38:23. 2. Thwaini A, Khan A, Malik A, et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006; 82:516-519. 3. Tuncel A, Aydin O, Tekdogan U, et al. 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Correspondence Saif Ghabisha, MD - saifalighabisha@yahoo.com Saleh Al-wageeh, MD - alwajihsa78@gmail.com Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen Faisal Ahmed, MD (Corresponding Author) fmaaa2006@yahoo.com Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen Mohamed Badheeb, MD - badheeb2009@gmail.com Internal Medicine Office, Yale New Haven/Bridgeport Hospital, CT (USA) Qasem Alyhari, MD - qalyhary@hotmail.com Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen Urology Office, Althora General Hospital, Alodine Street, Ibb (Yemen) Abdulfattah Altam, MD - dral_tam@yahoo.com Urology Office, School of Medicine, 21 September University, Sana'a (Yemen) Afaf Alsharif, MD - afafmussa2018@gmail.com Department of Gynaecology, School of Medicine, Jeblah University for Medical and Health Sciences, Ibb, Yemen Gynaecology Office, Jeblah Hospital, Jeblah, Ibb (Yemen) Conflict of interest: The authors declare no potential conflict of interest.