Published online Jun 9, 2026. doi: 10.5492/wjccm.v15.i2.117985
Revised: January 8, 2026
Accepted: January 27, 2026
Published online: June 9, 2026
Processing time: 152 Days and 12 Hours
Perineal necrotizing soft tissue infections (P-NSTI) are aggressive and potentially fatal conditions. Surgical fecal diversion (SFD) is often used to reduce contamination, but whether non-diversion provides comparable outcomes remains uncertain. We hypothesized that non-diversion does not confer worse outcomes than SFD.
To evaluate clinical outcomes of non-diversion compared with SFD in adults with P-NSTI.
Systematic review and meta-analysis following PRISMA and Cochrane standards. PubMed, EMBASE, Scopus, Web of Science and Cochrane Library were searched without date restrictions. Adults with P-NSTI comparing non-diversion vs SFD were included when outcomes were numerically extractable. Outcomes were mortality, hospital length of stay (LOS), number of surgical procedures and intensive care unit (ICU) admission. Random-effects models were used. Risk of bias was assessed with ROBINS-I and certainty of evidence with GRADE (PROSPERO CRD420251241839).
Thirty-six studies including 1751 patients were analyzed. In studies with reconstructed groups, mortality favored non-diversion, whereas no difference was observed in studies with predefined groups. Overall pooled analysis showed lower mortality with non-diversion (odds ratio 0.65; 95% confidence interval: 0.46-0.91; P = 0.01; I2 = 24%), limited by serious confounding by indication. Hospital LOS showed substantial heterogeneity; excluding one outlier study favored non-diversion. ICU admission and number of surgical procedures did not differ. Certainty of evidence was very low for all outcomes.
No consistent outcome differences are demonstrated between non-diversion and SFD, and apparent mortality differences likely reflect baseline severity rather than treatment effect, with insufficient evidence to define supe
Core Tip: This systematic review and meta-analysis of thirty-six studies found no consistent differences between non-diversion and surgical fecal diversion (SFD) in mortality, intensive care unit admission or the number of surgical procedures. Hospital length of stay showed significant heterogeneity, with sensitivity analysis favoring non-diversion after exclusion of one outlier study. Overall certainty of evidence was very low, mainly due to confounding by indication and inconsistent group definitions. These findings do not demonstrate a clear overall advantage of routine SFD and support the need for standardized criteria and prospective studies in Perineal necrotizing soft tissue infections.
- Citation: Ribeiro Junior MAF, M Henry S, Thalib HI, Khan S, Grochowska-Krystman A, Fontenelle Vieira L, Reddi S, Dib Possiedi R. Surgical fecal diversion vs non-diversion in perineal necrotizing soft tissue infections: A systematic review and meta-analysis. World J Crit Care Med 2026; 15(2): 117985
- URL: https://www.wjgnet.com/2220-3141/full/v15/i2/117985.htm
- DOI: https://dx.doi.org/10.5492/wjccm.v15.i2.117985
Perineal necrotizing soft tissue infection (P-NSTI), including the classical presentation known as Fournier’s gangrene, are rare, rapidly progressive and potentially fatal infections of the perineum and external genitalia. The estimated incidence is approximately 1.6 cases per 100000 men[1,2]. Despite advances in surgical and critical care, mortality remains high, with published series reporting rates between 7.5% and 45%[1]. A systematic review including 6152 patients documented an overall mortality of 19.8%[3], and more recent analyses have found average mortality near 7.3% in studies published after 2000[4]. In an institutional series among the present files, mortality reached 14%[1].
Standard management relies on broad spectrum antibiotics, intensive care support and aggressive repeated de
Recent narrative reviews suggest that surgical fecal diversion (SFD) may reduce the need for additional debridements and facilitate wound healing or graft uptake but highlight significant associated morbidity, including a 41% complication rate in one retrospective series, predominantly Clavien Dindo grade IIIb or higher[5]. Reported SFD rates vary widely, from 7%-67% across published cohorts[6], reflecting heterogeneous indications and the absence of standardized clinical criteria. Evidence regarding clinical benefit remains conflicting, and despite improvements in care, overall mortality in P-NSTI has not meaningfully declined in recent decades[2].
Only one prior meta-analysis has specifically examined SFD in this context, conducted by Sarofim et al[6] in 2021. That review pooled twenty seven retrospective cohorts without distinguishing whether treatment groups were predefined or reconstructed from survivors vs non-survivors. Several included studies did not report true comparative data, requiring inferred or artificially reconstructed mortality estimates. Indications for SFD varied widely and generally reflected more severe disease, yet no study level adjustment for confounding was performed. Although a Newcastle Ottawa Scale assessment was reported, no results were presented, limiting transparency. These issues reduce confidence in the pooled estimates and leave key methodological concerns unresolved.
Given the variability across studies, the inconsistent definition of comparison groups and the coexistence of cohorts employing both SFD and non-diversion strategies, a reassessment of the available evidence is needed. The present systematic review and meta-analysis was designed to identify all studies reporting outcomes separately for non-diversion and SFD, including those requiring reconstruction of treatment groups from narrative descriptions or tabulated data. The objective is to clarify the effect of SFD on mortality, hospital length of stay (LOS) and the number of operative deb
This systematic review and meta-analysis was conducted and reported in accordance with the Cochrane Handbook and the PRISMA guidelines[7,8]. Studies were selected according to the population, intervention, comparator, outcome, timing, and study design framework. The population consisted of adult patients with confirmed P-NSTI, including Fournier’s gangrene or necrotizing fasciitis of the perineum. The intervention of interest was non-diversion, defined as the absence of SFD. This included conservative fecal management methods such as bowel management catheters, Flexi-Seal® devices, endorectal tubes, or conventional wound care without diversion. The comparator was any form of surgical diversion of the fecal stream, including colostomy or ileostomy. Outcomes of interest included mortality, wound healing time, wound contamination or infection, number of surgical debridements, length of hospital stay, ICU admission and stay, and diversion-related or device-related complications. ICU admission was analyzed as a marker of baseline disease severity at presentation and resource utilization, rather than as a consequence of the diversion strategy. No restrictions were placed on publication date. Eligible study designs included randomized controlled trials, prospective and ret
Studies were excluded if they did not meet the predefined eligibility criteria. Exclusion criteria included pediatric populations, articles lacking original patient data, animal studies, reviews, commentaries, or editorials. Conference abstracts without extractable data were excluded, as were studies without clearly distinguishable SFD and non-diversion groups. Case series that reported aggregated outcomes without separation between patients who underwent SFD and those who did not were also excluded. No language restrictions were applied, provided that English data or an English abstract were available. The literature search included all comparative studies with no date restrictions.
This systematic review and meta-analysis was conducted according to a predefined protocol registered with the International Prospective Register of Systematic Reviews[9] on November 28, 2025, under registration number CRD4202512
Two independent reviewers conducted a systematic search of PubMed, Scopus, EMBASE, Cochrane, and Web of Science in November 2025. The search strategy used keywords linking P-NSTI to SFD and non-diversion strategies through terms such as “Fournier’s gangrene”, “necrotizing fasciitis”, “perineal sepsis”, “fecal diversion”, “colostomy”, “ileostomy”, “stoma”, “Flexi seal”, and “bowel management catheter”. The complete search approach for all databases appears in the Supplementary material.
A manual review of reference lists from included studies was performed to identify additional relevant publications for complete coverage. The selection of eligible studies followed established inclusion and exclusion criteria. The kappa statistics method was used to evaluate inter reviewer agreement on study selection, and the senior author made final decisions in cases of disagreement.
Two reviewers independently screened titles, abstracts, and full texts in Rayyan® according to the predefined eligibility criteria[10]. Disagreements were resolved through discussion, with a third reviewer consulted when needed.
Data were extracted using a standardized form developed for this review. Extracted variables included publication year, authors, country, and hospital or department of origin to identify potential overlap of patient populations, as well as study design and the number of patients in the non-diversion and SFD groups. Baseline characteristics were collected when available, including age, sex, comorbidities, origin of infection, severity at presentation, extent of necrosis, Fournier’s Gangrene Severity Index, and need for intensive care on admission.
Management data were recorded for both strategies, including the type of diversion procedure and non-diversion approaches such as bowel management catheters or conventional wound care. Information on the number of surgical debridements or operative procedures was also extracted.
Outcomes included mortality, wound healing time, wound contamination or infection, hospital LOS, ICU admission or stay, and diversion or device related complications. Follow up duration and postoperative observations were collected when reported.
When outcome data for non-diversion and SFD groups were presented narratively or embedded in tables, the values were extracted whenever clearly distinguishable. Medians were used as reported, and standard deviations were derived from standard errors when necessary.
Given the heterogeneity of study designs, two methodological structures were prespecified: Studies with predefined comparison groups and studies requiring reconstruction of comparison groups from narrative descriptions or tabulated data. In studies where non-diversion and SFD were not predefined as comparative exposure groups, data were extracted only when outcomes could be numerically separated according to treatment status. These studies were classified as retrospective observational cohorts with non-predefined exposure groups, and their data were included in quantitative analyses whenever numerical comparisons between strategies were extractable.
Only outcomes with consistent definitions and sufficient numerical detail across at least two studies were included in the quantitative synthesis. Outcomes with heterogeneous definitions or incomplete numerical reporting were not pooled.
The risk of bias was assessed independently by two reviewers using the ROBINS-I tool for non-randomized studies of interventions. Studies that reported outcomes stratified by non-diversion and SFD groups were evaluated as non-randomized comparative cohorts, even when originally designed as case series or descriptive cohorts. Seven domains were assessed for each study: Confounding, selection of participants, classification of interventions, deviations from intended management, missing data, measurement of outcomes, and selection of reported results. Particular attention was given to confounding by indication related to anatomical severity, wound contamination and physiological instability. Each domain was judged as low, moderate, serious, or critical risk of bias, and overall risk of bias classifications followed ROBINS-I guidance. Reviewers performed calibration using a subset of studies to standardize inter
Publication bias was assessed qualitatively using a structured approach suitable for heterogeneous observational evidence. The evaluation considered the distribution of study sizes, noting whether smaller studies contributed a disproportionate share of events or extreme effect estimates. Reporting patterns were reviewed to determine whether outcomes for diversion and non-diversion were presented consistently or selectively across studies. The completeness and balance of numerical outcome data were also examined, including whether both groups were reported with comparable detail within each study. In addition, publication chronology was assessed to identify potential temporal clustering that might suggest shifts in reporting or selective dissemination over time. These elements were appraised collectively to provide a descriptive assessment of potential publication bias.
Publication bias was formally assessed only for analyses supported by a sufficient number of comparative studies to allow a meaningful evaluation of small study effects. Funnel plots were generated using log transformed effect estimates and their standard errors, and asymmetry was examined with Egger’s regression test. For analyses with an insufficient number of contributing studies, publication bias was not evaluated, in accordance with established methodological guidance[7].
Statistical analyses followed a predefined plan appropriate for heterogeneous observational evidence. Pooled estimates were generated using random effects models to account for clinical and methodological variability across studies. Review Manager (RevMan)[11] was used to perform analyses and generate forest plots.
Dichotomous outcomes were synthesized using odds ratios (OR) with 95% confidence intervals (CI). Mortality was the primary dichotomous outcome, and effect sizes were calculated from raw event counts. Pooled estimates for dichotomous outcomes were calculated using the Mantel-Haenszel method under a random effects model, whereas continuous out
Continuous outcomes included hospital LOS and number of operative procedures. These were pooled as mean differences with 95%CI. When studies reported means and standard errors, standard deviations were calculated using SD = SEM × √n. For hospital LOS, values originally reported in months were converted to days using 30.44 days per month. Continuous outcomes were pooled only when at least two studies provided numerically convertible and methodologically comparable data. When medians were accompanied by dispersion measures, validated transformation methods were applied to estimate means and standard deviations when appropriate.
Between-study heterogeneity was quantified using the I2 and τ2 statistics[12]. I2 represents the proportion of total variability attributable to heterogeneity rather than chance, whereas τ2 estimates the variance of true effect sizes across studies. Statistical significance was defined as CI not crossing the null.
Sensitivity analyses were planned by re-running models after excluding studies identified as influential or contributing disproportionately to heterogeneity[7]. For hospital LOS, sensitivity analyses specifically evaluated the impact of studies reporting markedly divergent hospitalization durations that contributed disproportionately to between-study heterogeneity. In addition, analyses stratified by ROBINS-I classifications were prespecified and would be conducted if a sufficient number of studies at low or moderate risk of bias were available. In accordance with ROBINS-I guidance, studies judged at critical overall risk of bias would not contribute to quantitative effect estimates and would be included only in the narrative synthesis, without causal interpretation. Predefined subgroup analyses separated studies explicitly designed to compare non-diversion vs SFD from those in which comparative data were secondarily extracted from tables or descriptive text.
Five domains were evaluated: Risk of bias, inconsistency, indirectness, imprecision, and publication bias. For non-randomized observational evidence, including retrospective cohorts and case series, initial certainty ratings followed GRADE guidance for this type of study design, with further downgrading applied when concerns were identified in any domain. Final certainty ratings were determined independently for each outcome.
A total of 1725 records were identified across the five databases. After removing 622 duplicates, 1103 records were screened by title and abstract. Subsequently, 61 full-text reports identified through database screening were examined, of which 31 met the eligibility criteria. Backward citation searching identified an additional 5 eligible full-text reports. In total, 36 studies were included in the systematic review. No overlap of patient cohorts was identified after cross-checking institutions, recruitment periods, and hospital origin during the selection process. Ultimately, 26 cohort studies and 10 comparative case series were included[13-48], comprising a total of 1751 patients. Among them, 1168 were managed without fecal diversion and 583 underwent fecal diversion. Study characteristics are summarized in Supplementary Table 1, and the study selection process is detailed in Figure 1.
Ten studies[20,23,30,32,33,37-41] reported hospital LOS, including 251 patients in the non-diversion group and 197 in the SFD. In the primary random effects analysis, there was no significant difference between groups (MD -3.01 days; 95%CI: 10.75-4.74; P = 0.45), with substantial heterogeneity (I2 = 93%) (Figure 2A).
Because Mahmood et al[32] reported markedly longer LOS values than all other cohorts and contributed disproportionately to between study variability, a predefined sensitivity analysis was performed excluding this study. Heterogeneity decreased substantially (I2 = 75%), and the pooled effect favored non-diversion with a statistically significant reduction in LOS (MD -5.69 days; 95%CI: 10.89-0.49; P = 0.03).
Subgroup analysis showed consistent direction of effect in studies with predefined SFD and non-diversion groups and in those in which LOS was reconstructed from tables or narrative data (Figure 2B).
Four studies reported the proportion of patients requiring ICU care[17,32,37,39]. ICU admission occurred in 33 of 77 patients in the non-diversion group and in 34 of 66 patients in the SFD group. The pooled random effects analysis showed no significant difference between strategies (OR 0.65; 95%CI: 0.32-1.33; P = 0.24; I2 = 0%). The corresponding forest plot is shown in Figure 3A.
Nine studies reported the number of surgical procedures performed during hospitalization, including 182 patients in the non-diversion group and 190 patients in the SFD group. The pooled analysis showed no significant difference between strategies (MD -0.14; 95%CI: 0.68-0.40; P = 0.60; I2 = 80%)[14,17,20,32,33,37,39-41]. The corresponding forest plot is presented in Figure 3B.
Thirty three studies reported mortality[13-16,18-22,24-37,39-48], comprising 1080 patients in the non-diversion group, with 179 deaths, and 556 patients in the SFD, with 139 deaths.
Because mortality data were derived from studies with different structures of group definition, analyses were performed within two prespecified subgroups. In the first subgroup, composed of studies that did not define non-di
Across all studies combined, mortality remained lower in the non-diversion group (OR 0.65; 95%CI: 0.46-0.91; P = 0.01), with low overall heterogeneity (I2 = 24%). All mortality analyses were based on unadjusted observational data extracted from non-randomized cohorts. The forest plot for this analysis is presented in Figure 3C.
A complete ROBINS-I assessment is provided in Supplementary Table 2. Thirty-six studies were judged to be at serious overall risk of bias, mainly due to confounding by indication, as SFD was more commonly performed in patients with more extensive anatomical involvement, sphincter injury, rectal perforation, delayed presentation or more advanced physiological compromise[13,14,19,21,23,26-28,33-41,44-46,48].
Selection of participants was judged to be at serious risk of bias in all studies. Although eight retrospective cohorts were explicitly designed to compare SFD and non-diversion[14,20,30,32,33,37,39,40], the remaining cohorts and case series did not predefine eligibility criteria or treatment allocation for comparative assessment, resulting in non-prespecified exposure groups[13,15-19,21,22,24-29,31,34-36,41-48].
All studies were judged to have a serious risk of bias in the classification of interventions. Although eight retrospective cohorts were explicitly designed to compare SFD and non-diversion[14,20,30,32,33,37,39,40], treatment allocation was not based on standardized criteria, but rather on clinical judgment, patient preference, or the perceived severity of disease. The remaining cohorts and case series reported SFD as a descriptive characteristic without prespecified eligibility criteria or exposure definitions, and intervention status was extracted secondarily from operative reports, tables, or narrative descriptions[13,15-19,21,22,24-29,31,34-36,41-48]. In all studies, classification of SFD therefore reflected prognostic di
Deviations from intended interventions were judged to be at serious risk of bias in all studies, because postoperative management frequently differed between SFD and non-diverted patients and reflected underlying disease severity rather than standardized protocols. In several studies, the timing and subsequent management of SFD were insufficiently reported to determine whether postoperative care differed systematically, reinforcing the presence of serious bias in this domain but without meeting criteria for exclusion[13-48].
Reporting of missing data varied across studies. Twenty-one studies were judged to be at low risk, as outcome data were complete or missingness was minimal and clearly unrelated to prognostic severity[13,19,20,24-27,29-32,35,37,39-43,45-47]. Fourteen studies were rated as moderate risk due to partially missing laboratory, severity, or follow-up data that limited baseline comparability or secondary outcomes[14-18,21-23,28,33,34,36,44,48]. One study showed serious risk, with incomplete follow-up and missing outcome data that disproportionately affected the diverted group[38].
Measurement of outcomes was consistently judged as low risk of bias, because the clinical endpoints reported in each study (such as mortality, LOS or number of operative procedures) were objectively defined and recorded using routine clinical data[13-48]. In 32 studies, selection of reported results was judged as moderate risk due to incomplete outcome reporting without evidence of outcome suppression[13-35,37,39-43,45-47]. Four studies demonstrated serious risk, as several collected outcomes were not reported at all or were selectively suppressed when comparing strategies[36,38,44,48].
Overall, all studies were judged to be at serious risk of bias, primarily due to severity-dependent allocation of SFD, resulting in limited comparability between non-diversion and SFD groups across both cohorts and case series[13-48].
The funnel plot for mortality demonstrated a broad symmetric distribution of log OR around the pooled estimate. Smaller studies were more widely dispersed at the base of the plot, as expected, and no clear directional asymmetry suggestive of publication bias was observed (Figure 4A).
An exploratory funnel plot was generated for hospital LOS (10 studies). The plot appeared asymmetric; however, because of the limited number of studies and substantial clinical and methodological heterogeneity, this pattern cannot be interpreted as evidence of publication bias (Figure 4B).
According to the GRADE framework, all outcomes were rated as very low certainty. This rating reflected the predominance of retrospective observational designs, serious risk of bias across multiple ROBINS I domains, substantial heterogeneity for several outcomes, small sample sizes in some analyses, and wide CI indicating imprecision. No outcome met criteria for upgrading. Detailed GRADE ratings for each outcome are presented in Supplementary Table 3.
Mortality was the key clinical outcome in this review, and the pooled analysis showed lower mortality in the non-diversion group. A closer examination of study design, however, revealed that this association depended strongly on how treatment groups were defined in the primary studies. Cohorts that prespecified non diversion and SFD groups at baseline[14,20,30,32,33,37,39,40] demonstrated no significant difference in mortality between strategies. In contrast, studies in which mortality data required reconstruction from case tables or narrative descriptions[13,15-19,21,22,24-29,31,34-36,41-48] tended to favor non diversion. This divergence is best explained by differences in methodological structure rather than by a true therapeutic effect.
The only previous meta-analysis specifically examining SFD in Fournier’s gangrene, conducted by Sarofim et al[6], pooled all available studies without distinguishing whether treatment groups were defined a priori or reconstructed from survivors vs non survivors. This approach combined heterogeneous designs with fundamentally different risk profiles, which likely distorted the pooled estimate. Many of the studies contributing to the apparent survival advantage of non diversion in that review are precisely those in which SFD was performed selectively in clinically unstable patients, making confounding by indication unavoidable. By separating studies with predefined groups from those requiring reconstruction, the present review provides a more coherent framework for interpreting mortality patterns and reduces exposure misclassification, which was a major limitation in previous analyses.
Taken together, these findings do not support the interpretation that non diversion is inherently protective. SFD was frequently offered to patients with greater physiological compromise, more extensive necrosis, sphincter or rectal involvement, or heavier perineal contamination[13,14,19,21,23,26-28,33-41,44-46,48]. These factors were inconsistently reported and rarely balanced across groups, explaining why the apparent benefit of non diversion in pooled analyses is more plausibly driven by underlying differences in patient severity than by the effect of the intervention itself. The very low certainty of evidence for mortality further supports this interpretation and underscores the limitations of inferring treatment effects from retrospective comparisons. No included study adjusted for anatomical severity, physiological instability, or source control, which are major determinants of both SFD decision and mortality.
Important outcomes such as wound healing, wound contamination and SFD-related complications could not be synthesized quantitatively due to inconsistent reporting and lack of stratified data.
Secondary outcomes demonstrated similar limitations. Hospital LOS varied widely across studies, reflecting di
The assessment of publication bias for mortality showed no clear directional asymmetry. However, in observational evidence where confounding by indication is pervasive, funnel plot symmetry does not exclude the possibility of selective publication. For hospital LOS, the funnel plot appeared asymmetric, but the small number of studies and substantial clinical heterogeneity prevent reliable interpretation, and no conclusions regarding publication bias can be drawn.
Overall, limitations of the primary literature remain the primary barrier to certainty rather than publication-related distortion.
According to the GRADE framework, all outcomes were rated as very low certainty, reflecting the predominance of retrospective designs, high risk of bias across multiple ROBINS I domains, small samples in several analyses, substantial heterogeneity, and wide CI that made the estimates imprecise. Under ROBINS I guidance effect estimates from non-randomized studies at serious risk of bias cannot be interpreted as causal. In this review, quantitative synthesis was retained to describe observed outcome patterns in a rare and understudied condition, but these findings were interpreted as very low certainty and considered hypothesis-generating rather than confirmatory. This approach aligns the statistical analysis with the methodological constraints of the primary evidence. No outcome met criteria for upgrading. These ratings reinforce that the findings should be interpreted with caution and that meaningful comparisons between SFD and non-diversion remain limited by the quality of the available data.
This review has important strengths, including the largest dataset assembled to date, a structured approach to recon
Nonetheless, significant limitations must be acknowledged. Nearly all included studies were retrospective, lacked standardized criteria for SFD, and frequently omitted essential severity measures. Many studies did not define treatment groups, requiring reconstruction of exposure categories from survivors vs non survivors tables[13,15,16,18,19,21,22,24,27,29,36,41-43,45-47], a method susceptible to misclassification. Residual confounding is unavoidable because SFD was con
In summary, the current evidence does not support a definitive survival benefit for either SFD or non diversion. Apparent differences in mortality are more plausibly explained by confounding and methodological limitations than by treatment effect. Until higher quality evidence becomes available, decisions regarding SFD should continue to be individualized, taking into account anatomical involvement, degree of contamination, sphincter or rectal injury, and overall physiological stability.
This systematic review and meta-analysis found no reliable evidence that either non diversion or SFD improves survival or other clinically relevant outcomes in P-NSTI. Observed differences across studies were largely explained by un
Artificial intelligence tools were used to assist with deduplication and citation management (Zotero), study screening (Rayyan), plagiarism checking (Ref-n-write), language editing (ChatGPT), and statistical analysis (RevMan) during manuscript preparation. The authors reviewed and approved all AI-generated content and are fully responsible for its accuracy and integrity.
| 1. | Oguz A, Gümüş M, Turkoglu A, Bozdağ Z, Ülger BV, Agaçayak E, Böyük A. Fournier's Gangrene: A Summary of 10 Years of Clinical Experience. Int Surg. 2015;100:934-941. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 23] [Cited by in RCA: 38] [Article Influence: 3.5] [Reference Citation Analysis (0)] |
| 2. | Zhang KF, Shi CX, Chen SY, Wei W. Progress in Multidisciplinary Treatment of Fournier's Gangrene. Infect Drug Resist. 2022;15:6869-6880. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 2] [Cited by in RCA: 18] [Article Influence: 4.5] [Reference Citation Analysis (0)] |
| 3. | Radcliffe RS, Khan MA. Mortality associated with Fournier's gangrene remains unchanged over 25 years. BJU Int. 2020;125:610-616. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 10] [Cited by in RCA: 34] [Article Influence: 5.7] [Reference Citation Analysis (0)] |
| 4. | Bowen D, Juliebø-Jones P, Somani BK. Global outcomes and lessons learned in the management of Fournier's gangrene from high-volume centres: findings from a literature review over the last two decades. World J Urol. 2022;40:2399-2410. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 2] [Cited by in RCA: 18] [Article Influence: 4.5] [Reference Citation Analysis (0)] |
| 5. | Huang S, Chen DC, Perera M, Lawrentschuk N. Role of diverting colostomy and reconstruction in managing Fournier's gangrene-a narrative review. BJU Int. 2024;134:534-540. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 3] [Reference Citation Analysis (0)] |
| 6. | Sarofim M, Di Re A, Descallar J, Toh JWT. Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis. Langenbecks Arch Surg. 2021;406:2581-2590. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 1] [Cited by in RCA: 12] [Article Influence: 2.4] [Reference Citation Analysis (0)] |
| 7. | Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA. Cochrane Handbook for Systematic Reviews of Interventions. 2nd Edition. Chichester, United Kingdom: John Wiley & Sons, 2019. |
| 8. | Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 57226] [Cited by in RCA: 48266] [Article Influence: 2839.2] [Reference Citation Analysis (11)] |
| 9. | Dib Possiedi R, Fontenelle Ribeiro Junior MA, Henry SM, Irfan Thalib H, Khan S, Grochowska Krystman A, Fontenelle Vieira L, Reddi S. PROSPERO: Fecal diversion versus non-diversion in Perineal Necrotizing Infections: a systematic review and meta-analysis. PROSPERO 2025 CRD420251241839. Available from: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251241839. |
| 10. | Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 18843] [Cited by in RCA: 15485] [Article Influence: 1548.5] [Reference Citation Analysis (6)] |
| 11. | Review Manager (RevMan). 2025. Available from: https://revman.cochrane.org/info. |
| 12. | Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539-1558. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 31036] [Cited by in RCA: 27160] [Article Influence: 1131.7] [Reference Citation Analysis (3)] |
| 13. | Aijaz SM, Zargar MT, Bhat GA, Wani MA, Youuf J. Predictive factors and treatment outcomes in fournier’s gangrene: a retrospective analysis of clinical management and prognosis. Int J Acad Med Pharm. 2025;7:1011-1016. |
| 14. | Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E. Necessity of preventive colostomy for Fournier's gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg. 2009;15:342-346. [PubMed] |
| 15. | Chan BY, Wong BW, Lo KK, Yim C, Tse CT. Fournier's gangrene: A 10‐year review and validation of mortality predictors in a Hong Kong major regional centre. Surg Pract. 2018;22:60-66. [RCA] [DOI] [Full Text] [Cited by in Crossref: 2] [Cited by in RCA: 3] [Article Influence: 0.4] [Reference Citation Analysis (0)] |
| 16. | Çitgez S, Demirdağ Ç, Özkaya M, Selçuk B, Erözenci A. Fournier’s Gangrene: Analysis of Risk Factors Affecting Mortality in a Tertiary Urology Referral Center. J Urol Surg. 2019;6:196-200. [RCA] [DOI] [Full Text] [Cited by in Crossref: 3] [Cited by in RCA: 7] [Article Influence: 1.0] [Reference Citation Analysis (0)] |
| 17. | Corman JM, Moody JA, Aronson WJ. Fournier's gangrene in a modern surgical setting: improved survival with aggressive management. BJU Int. 1999;84:85-88. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 60] [Cited by in RCA: 48] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
| 18. | Dahm P, Roland FH, Vaslef SN, Moon RE, Price DT, Georgiade GS, Vieweg J. Outcome analysis in patients with primary necrotizing fasciitis of the male genitalia. Urology. 2000;56:31-5; discussion 35. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 64] [Cited by in RCA: 59] [Article Influence: 2.3] [Reference Citation Analysis (0)] |
| 19. | Eğin S, Kamalı S, Hot S, Gökçek B, Yeşiltaş M, Duman MG, Alemdar A. The importance of the scoring system in Fournier's gangrene. Ulus Travma Acil Cerrahi Derg. 2022;29:109-115. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 5] [Reference Citation Analysis (0)] |
| 20. | Eray IC, Alabaz O, Akcam AT, Ulku A, Parsak CK, Sakman G, Seydaoglu G. Comparison of Diverting Colostomy and Bowel Management Catheter Applications in Fournier Gangrene Cases Requiring Fecal Diversion. Indian J Surg. 2015;77:438-441. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 17] [Cited by in RCA: 21] [Article Influence: 1.6] [Reference Citation Analysis (0)] |
| 21. | Ersay A, Yilmaz G, Akgun Y, Celik Y. Factors affecting mortality of Fournier's gangrene: review of 70 patients. ANZ J Surg. 2007;77:43-48. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 70] [Cited by in RCA: 71] [Article Influence: 3.7] [Reference Citation Analysis (0)] |
| 22. | Ersoz F, Sari S, Arikan S, Altiok M, Bektas H, Adas G, Poyraz B, Ozcan O. Factors affecting mortality in Fournier's gangrene: experience with fifty-two patients. Singapore Med J. 2012;53:537-540. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 1] [Reference Citation Analysis (0)] |
| 23. | Eksi M, Arikan Y, Simsek A, Ozdemir O, Karadag S, Gurbuz N, Sahin S, Tasci AI. Factors affecting length of stay in Fournier's gangrene: a retrospective analysis of 10 years' data. Aktuelle Urol. 2022;53:262-268. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 3] [Cited by in RCA: 8] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
| 24. | García Marín A, Turégano Fuentes F, Cuadrado Ayuso M, Andueza Lillo JA, Cano Ballesteros JC, Pérez López M. Predictive factors for mortality in Fournier' gangrene: a series of 59 cases. Cir Esp. 2015;93:12-17. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 14] [Cited by in RCA: 22] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
| 25. | Gürdal M, Yücebas E, Tekin A, Beysel M, Aslan R, Sengör F. Predisposing factors and treatment outcome in Fournier's gangrene. Analysis of 28 cases. Urol Int. 2003;70:286-290. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 46] [Cited by in RCA: 41] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
| 26. | Hong KS, Yi HJ, Lee RA, Kim KH, Chung SS. Prognostic factors and treatment outcomes for patients with Fournier's gangrene: a retrospective study. Int Wound J. 2017;14:1352-1358. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 20] [Cited by in RCA: 37] [Article Influence: 4.1] [Reference Citation Analysis (0)] |
| 27. | Hung M, Chou C, Cheng L, Ho C, Niu K, Chen H, Tian Y, Liu C. The role of hyperbaric oxygen therapy in treating extensive Fournier's gangrene. Urol Sci. 2016;27:148-153. [RCA] [DOI] [Full Text] [Cited by in Crossref: 7] [Cited by in RCA: 12] [Article Influence: 1.2] [Reference Citation Analysis (0)] |
| 28. | Kiliç A, Aksoy Y, Kiliç L. Fournier's gangrene: etiology, treatment, and complications. Ann Plast Surg. 2001;47:523-527. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 45] [Cited by in RCA: 41] [Article Influence: 1.6] [Reference Citation Analysis (0)] |
| 29. | Korkut M, Içöz G, Dayangaç M, Akgün E, Yeniay L, Erdoğan O, Cal C. Outcome analysis in patients with Fournier's gangrene: report of 45 cases. Dis Colon Rectum. 2003;46:649-652. [PubMed] [DOI] [Full Text] |
| 30. | Li YD, Zhu WF, Qiao JJ, Lin JJ. Enterostomy can decrease the mortality of patients with Fournier gangrene. World J Gastroenterol. 2014;20:7950-7954. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in CrossRef: 20] [Cited by in RCA: 16] [Article Influence: 1.3] [Reference Citation Analysis (0)] |
| 31. | Lin HC, Chen ZQ, Chen HX, He QL, Liu ZM, Zhou ZY, Shi R, Ren DL. Outcomes in patients with Fournier's gangrene originating from the anorectal region with a particular focus on those without perineal involvement. Gastroenterol Rep (Oxf). 2019;7:212-217. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 5] [Cited by in RCA: 10] [Article Influence: 1.4] [Reference Citation Analysis (0)] |
| 32. | Mahmood BA, ElSayed EH, Ali SA. Effect of Colostomy on Treatment Outcome in Fournier Gangrene: A Prospective Comparative Study. Plast Surg (Oakv). 2023;31:24-28. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 2] [Reference Citation Analysis (0)] |
| 33. | Mayoral V, Coquerel-Beghin D, Cornu JN, Bridoux V, Auquit-Auckbur I, Pfister C. Impact of fecal diversion in Perineal Necrotizing Soft Tissue Infection on disease survival: A large retrospective study. Surg Pract Sci. 2024;16:100231. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 1] [Cited by in RCA: 3] [Article Influence: 1.5] [Reference Citation Analysis (0)] |
| 34. | Mehl AA, Nogueira Filho DC, Mantovani LM, Grippa MM, Berger R, Krauss D, Ribas D. Management of Fournier's gangrene: experience of a university hospital of Curitiba. Rev Col Bras Cir. 2010;37:435-441. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 24] [Cited by in RCA: 29] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
| 35. | Omisanjo OA, Bioku MJ, Ikuerowo SO, Sule GA, Esho JO. Clinical characteristics and outcome of management of Fournier's gangrene at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria. Ann Afr Med. 2014;13:174-178. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 4] [Cited by in RCA: 5] [Article Influence: 0.4] [Reference Citation Analysis (0)] |
| 36. | Ortega Ferrete A, López E, Juez Sáez LD, García-Pérez JC, Ocaña J, Ballestero A, Fernández-Cebrián JM, Die Trill J. Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform? Langenbecks Arch Surg. 2023;408:428. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 3] [Reference Citation Analysis (0)] |
| 37. | Ozturk E, Sonmez Y, Yilmazlar T. What are the indications for a stoma in Fournier's gangrene? Colorectal Dis. 2011;13:1044-1047. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 28] [Cited by in RCA: 27] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
| 38. | Ozkan OF, Koksal N, Altinli E, Celik A, Uzun MA, Cıkman O, Akbas A, Ergun E, Kiraz HA, Karaayvaz M. Fournier's gangrene current approaches. Int Wound J. 2016;13:713-716. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 41] [Cited by in RCA: 35] [Article Influence: 3.5] [Reference Citation Analysis (0)] |
| 39. | Planellas Giné P, Rodríguez‐Hermosa JI, Codony Bassols C, Marinello F, Salvador Roses H, Gil Garcia J, Gómez Romeu N, Julià Bergkvist D, Farrés Coll R, Codina‐Cazador A. Role of derivative colostomy in Fournier’s gangrene: Analysis of 46 cases. Surg Pract. 2017;21:111-115. [DOI] [Full Text] |
| 40. | Rosen DR, Brown ME, Cologne KG, Ault GT, Strumwasser AM. Long-term follow-up of Fournier's Gangrene in a tertiary care center. J Surg Res. 2016;206:175-181. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 8] [Cited by in RCA: 12] [Article Influence: 1.2] [Reference Citation Analysis (0)] |
| 41. | Simsek Celik A, Erdem H, Guzey D, Celebi F, Birol S, Erozgen F, Kaplan R. Fournier's gangrene: series of twenty patients. Eur Surg Res. 2011;46:82-86. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 10] [Cited by in RCA: 10] [Article Influence: 0.6] [Reference Citation Analysis (0)] |
| 42. | Tarchouli M, Bounaim A, Essarghini M, Ratbi MB, Belhamidi MS, Bensal A, Zemmouri A, Ali AA, Sair K. Analysis of prognostic factors affecting mortality in Fournier's gangrene: A study of 72 cases. Can Urol Assoc J. 2015;9:E800-E804. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 16] [Cited by in RCA: 26] [Article Influence: 2.4] [Reference Citation Analysis (0)] |
| 43. | Kilinc Tuncer G, Tuncer K, Aydogan S. Do Stoma Formation and Use of Vacuum Assisted Closure System Affect Mortality in Perineal Fournier's Gangrene? J Coll Physicians Surg Pak. 2023;33:145-148. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 2] [Reference Citation Analysis (0)] |
| 44. | Unal B, Kocer B, Ozel E, Bozkurt B, Yildirim O, Altun B, Dolapci M, Cengiz O. Fournier gangrene. Approaches to diagnosis and treatment. Saudi Med J. 2006;27:1038-1043. [PubMed] |
| 45. | Unalp HR, Kamer E, Derici H, Atahan K, Balci U, Demirdoven C, Nazli O, Onal MA. Fournier's gangrene: evaluation of 68 patients and analysis of prognostic variables. J Postgrad Med. 2008;54:102-105. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 43] [Cited by in RCA: 46] [Article Influence: 2.7] [Reference Citation Analysis (0)] |
| 46. | Villanueva-Sáenz E, Martínez Hernández-Magro P, Valdés Ovalle M, Montes Vega J, Alvarez-Tostado F JF. Experience in management of Fournier's gangrene. Tech Coloproctol. 2002;6:5-10; discussion 11. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 42] [Cited by in RCA: 48] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
| 47. | Wong R, Blachman-Braun R, Mann U, Eng A, Lother S, Patel P. Location of residence and mortality for patients diagnosed with Fournier's gangrene. Can Urol Assoc J. 2021;15:E267-E271. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 3] [Cited by in RCA: 4] [Article Influence: 0.8] [Reference Citation Analysis (0)] |
| 48. | Yağcı G, Zeybek N, Görgülü S, Yıldız R, Dündar K, Şimşek A, Çetiner S, Şen D. Value of Hyperbaric Oxygen Treatment in the Management of Patients with Fournier’s Gangrene. Gulhane Med J. 2005;47:34-39. |