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CASE STUDY Karen Fitzmaurice
Urology Cancer Coordinator Tallaght Hospital
Presentation• 25 yr old single
man• No PMX of note• Sept 2012
generally unwell• Weight loss• Fever• Night sweats
• Seen by GP
• CT – large retroperitoneal mass
15 x 12 x 11cms
• Referred to Oncology
Presentation
• Tumour Markers
• AFP – 1.0 (0 - 5.0)• HCG – 6.2 (<5 )• LDH – 2475 (100 - 350)
• Testicular exam - NAD
• Bx. of mass – extra gonadal germ cell tumour – embryonal carcinoma.
• Sperm banking attempted - no sperm seen
Treatment
• 4 cycles EP (Etoposide & Cysplatin)
• Complicated by intrahepatic thrombosis of the IVC
• Commenced Clexane
• CT - mass reduced in size to
5.2 x 4.2 x 3.7 cms
• Referred to Mr Thornhill
Surgery
• Extensive RPLND on 24/05/2013 - mass was densely adherent and required an arterial graft from aorta to the right iliac artery.
• Operating time 8 ½ hours
• EBL= 3,600mls
• Developed right leg ischemia in the recovery room & returned to theatre
Exploration of graft with popliteal &
pedal embolectomy
• Significant amount of thrombus recovered
• Transferred to ICU
1ST Day Post Op
• Developed right leg pain & reduced ankle movement.
• Possible compartment syndrome (increased pressure within a muscle compartment)
• Patients are at higher risk of compartment syndrome when a blood vessel is damaged & subsequently repaired through surgery.
Right Calf Fasciotomy
Closure of medial fasciotomy &VAC dressing to lateral
fasciotomy 27/05/13
Post Operative care
• MDT – nursing & medical staff, dietician, physiotherapy, Pain team, occupational health, discharge planning.
• PCEA • TPN• NPO, N/G, central line• U/C • Clips & tension sutures• Heparin x 7 days then
clexane
• 6/7 ICU• Weight bear 3/7 post op• Exercises - prevent foot
drop• Resting calf splint • Mobilising frame 2/52 post
op. • Vac dressing x 15 days• Occupational health home
visit• Discharged on 12/06/13
Discharge
• Convalescence x 1/52• Community physiotherapy• 24/07/13 seen in clinic for histology
results – no evidence of residual viable tumour.
• D/C from urology to oncology.• October 2013 – resumed normal
activity i.e. swimming & cycling.• Continues to attend physiotherapy
sessions.