|Year : 2020 | Volume
| Issue : 2 | Page : 75-77
Anesthetic management of urinary bladder paraganglioma
Priyanka Singh, Jasvinder Kohli, MD Kaur
Department of Anaesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Hospital, New Delhi, India
|Date of Submission||29-Dec-2019|
|Date of Decision||19-Mar-2020|
|Date of Acceptance||31-Mar-2020|
|Date of Web Publication||11-May-2020|
Dr, Priyanka Singh
Department of Anaesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Extra-adrenal paraganglioma is a rare neuroendocrine tumor that produces stores and secretes catecholamine. The mainstay in the management of the patients posted for resection of these tumors includes adequate preoperative preparation, good collaboration between the surgeons and the anesthesiologist, and use of modern anesthetic drugs and advanced monitoring to avoid any hemodynamic fluctuations intraoperatively. These will decrease the rate of complications and improve the overall outcome of such surgeries.
Keywords: Alpha-adrenergic blocker, catecholamine, paraganglioma, urinary bladder
|How to cite this article:|
Singh P, Kohli J, Kaur M D. Anesthetic management of urinary bladder paraganglioma. Bali J Anaesthesiol 2020;4:75-7
| Introduction|| |
Tumors of chromaffin cells, derived from the embryonic neural crest, usually originate from the adrenal medulla and are designated as pheochromocytoma. However, 10% of these tumors occur at extra-adrenal sites and known as paraganglioma. Extra-adrenal paraganglioma develops predominantly in the organ of Zuckerlandl and also in the thorax, abdomen, pelvis, mediastinum, and neck. Bladder paraganglioma are extremely rare tumors accounting for 0.06% of all the urinary bladder neoplasms, with clinical manifestations ranging from hypertension to hematuria to being asymptomatic.
Paraganglioma presents a challenge to the anesthesiologist because of its clinical features and implications. The patient must be treated before surgery until stable hemodynamic state is achieved. Preoperative treatment includes alpha-2 short-acting adrenergic blockers and beta-blocking agents. The most crucial intraoperative moments are induction of anesthesia and hemodynamic oscillations. We here describe the successful management of a case of extra-adrenal pheochromocytoma involving the base of the bladder posted for laparoscopic excision of the tumor.
| Case Report|| |
A 43-year-old male presented with a history of intermittent headache and palpitation for three years, which occurs mainly after exertion. The patient also started developing difficulty in micturition from the past 1 year. There was no history of any chest pain, breathlessness, syncopal attacks, and visual disturbances.
On examination, pulse rate was 96/min, and his blood pressure (BP) was 150/100 mmHg in supine position and 140/100 mmHg in standing position. Other physical examinations were unremarkable. The laboratory investigations, including thyroid function tests, revealed no abnormality.
Electrocardiography (ECG) was interpreted as normal sinus rhythm, with two-dimensional echocardiography revealing mild concentric left ventricular (LV) hypertrophy with LV ejection fraction of 60%. Ultrasonography abdomen detected a soft-tissue mass approximately 2 cm × 2 cm in size, abutting the superior surface of the prostate, seen projecting in the bladder. Abdominal computed tomography showed a well-defined enhancing mass in relation to the base of the urinary bladder as described neuroendocrine tumor [Figure 1] and [Figure 2]. The investigation for 24-h urinary norepinephrine level was increased at 322.44 μg/day (normal level: 23–105 μg/day). He was taking prazosin 2.5 mg (once daily) and propranolol 20 mg (once daily) for 4 weeks before admission.
|Figure 1: CECT abdomen showing well defined enhancing mass at the base of bladder|
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On the day before surgery, his pulse rate was 80/min and BP was 122/86 mmHg in supine and 116/80 mmHg in standing position. Alprazolam 0.5 mg was prescribed on the night before surgery, and both prazosin and propranolol were continued until the morning of surgery. Written informed high-risk consent was taken, and blood transfusion products were ordered.
The patient was planned under general anesthesia and was taken to the operation room where ECG, BP, and SaO2 were monitored. On presentation at the operating room, the patient's supine BP was 119/82 mmHg and pulse rate of 63/min. Two large-bore peripheral intravenous lines were secured. We administered midazolam 1 mg as premedication. An arterial line was inserted at the left radial artery, and the right internal jugular vein was cannulated for central venous pressure (CVP) monitoring.
Induction of anesthesia was carried out with propofol 80 mg and fentanyl 100 mcg, and vecuronium 6 mg was administered for muscle relaxation. Xylocard 1.5 mg/kg was given 90 seconds before laryngoscopy. An endotracheal tube was inserted without any rise in BP. All required pharmacological agents, such as nitroglycerine (NTG), esmolol, phenylephrine, and noradrenaline, were kept ready.
The surgery was commenced 15 min after induction with a stable course of hemodynamic. There was a transient fall in systolic BP at the time of pneumoperitoneum creation, which was managed with a rapid infusion of around 200 ml of crystalloids. Due to tumor manipulation and catecholamine release, the BP increased to up to 186/110 mmHg (after 75 min of induction) which was managed by infusion of NTG (titrated from 5–100 mcg/kg/min).
NTG was tapered just before ligation of tumor in order to avoid precipitous fall in BP. Tumor vein ligation and clamping triggered a reduction in BP which was managed with continuous infusion of norepinephrine. During the whole procedure, CVP was maintained to around 6–10 cm H2O. Blood glucose levels were also within normal limits. As it was laparoscopic surgery, we expected lesser blood loss. The estimated blood loss was around 500 ml, which was managed with 3 l of crystalloids and one unit of packed red blood cells. Urine output was adequate, and temperature was maintained throughout the surgery.
Considering that it was a laparoscopic procedure and the fact that the patient kept stable intraoperative course mostly (with few episodes of hemodynamic fluctuations) which was managed effectively, we decided to extubate the patient taking all measures to avoid any instability of vital signs. He was extubated successfully, with no neurological deficits observed in the postoperative period. The patient was discharged 2 days later, without any complication.
| Discussion|| |
While pheochromocytoma with adrenal localization is observed in the fourth and fifth decades and mostly in females, the ones with extra-adrenal localization are found in the second and third decades and primarily in males. Our patient was a 43-year-old male in his fourth decade. The symptoms of extra-adrenal paraganglioma could be due to catecholamine excess, which are similar to pheochromocytoma, as well as due to the specific location of tumors, which may help in localizing the tumors.
Pheochromocytomas are important to anesthesiologists because 25%–30% of hospital deaths occur in patients during induction of anesthesia and intraoperatively. Intubation, laryngoscopy, pneumoperitoneum, and manipulation of the adrenal gland can induce catecholamine secretion and consequently lead to a hypertensive crisis. The objectives of preoperative care include arterial pressure control, reversal of chronic circulating volume depletion, heart rate (HR) and arrhythmia control, reversal of glucose, and electrolyte disturbances. Alpha-adrenergic blockers and beta-blockers are used traditionally to control BP and HR.
Phenoxybenzamine, a nonselective, non-competitive, long-acting alpha-adrenergic blocker for many years, has been a mainstay of therapy but causes reflex tachycardia and hypotension., In our case, prazosin, an alpha-2 selective blocker that does not cause reflex tachycardia with a shorter half-life, was used in preoperative period.
The chosen anesthetic technique should be to avoid drug-induced catecholamine release, avoid catecholamine release induced by anesthetic or surgical maneuvers, minimize hemodynamic responses to tumor handling, and treat episodes of hypotension, particularly after tumor devascularization. Frequent communication between surgeons and anesthetists is extremely important to avoid intraoperative complications.
There are some medications such as nitroprusside, NTG, and phentolamine mesylate recommended for the preparation for the intervention of intraoperative hypertension that may develop in these patients, especially during induction, intubation, pneumoperitoneum, and manipulation of the mass., We prepared NTG infusion to deal with intraoperative rise of BP during induction as well as tumor handling. Drugs such as ketamine, ephedrine, succinylcholine, metoclopramide, desflurane, pancuronium, and atracurium are to be avoided in such cases.
To conclude, paraganglioma surgeries require proper preoperative preparation to avoid serious intraoperative consequences of hypertensive crisis. The present case, with bladder base as extra-adrenal site and not the aorta or any vital structures, experienced relatively controlled hemodynamic fluctuations. The patient was not on any inotrope at the end of surgery. The successful anesthetic management of this case was attributed to both preoperative optimizations as well as vigilant intraoperative monitoring.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]