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 ( ) HCG – 6.2 (<5 ) LDH – 2475 ( ) 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/ 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

1 ST 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.