Re

Abstract

Letters 635likely due to the ipsilateral sympathectomy. His weakness and postural hypotension resolved over a period of 10 days. DiscussionPatients with testicular cancer typically belong to a younger age group (15-40 years old). These patients are often treated successfully with combined chemotherapy and radical surgery. The surgery involves extensive thoracoabdominal dissection and requires an incision from the lower abdomen to lateral chest at approximate level T5. 1 Postoperatively, an epidural allows effective pain relief, early return of bowel function, and decreased incidence of respiratory complications. Epidural also may mask any neurological symptoms that are directly related to surgery.Aggressive and extensive dissection involves removal of retroperitoneal tissues that coincidentally include sympathetic ganglia, sympathetic chains, and nerve fibers. Often the nerves of the lumbar and sacral plexus may be stretched which may explain transient postoperative numbness and weakness. The postural hypotension is due to lower extremity vascular pooling resulting from a sympathectomy coincidental to the surgical dissection. Vascular dilation can also result from thrombosis of the iliac vein or inferior vena cava. In extreme cases, a venogram or ultrasound should be performed to exclude this. Under-hydration serves to aggravate the hypotension. In rare circumstances, the artery of Adamkovich may also be damaged during left-sided procedures, leading to postoperative paraplegia that may be blamed on an epidural. 2 We have observed that patients who do not receive epidurals also develop weakness and postural hypotension which may be directly attributable to the surgical procedure.