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LETTER TO EDITOR
Year : 2013  |  Volume : 29  |  Issue : 4  |  Page : 574-576

Undiagnosed bladder pheochromocytoma: An anesthetic challenge


1 Departments of Anaesthesia, Padmashree Dr. D. Y. Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India
2 Departments of Uro Surgery, Padmashree Dr. D. Y. Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication1-Oct-2013

Correspondence Address:
Sonal S Khatavkar
Department of Anaesthesia, Padmashree Dr. D. Y. Patil Medical College and Hospital, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.119165

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How to cite this article:
Khatavkar SS, Raje DM, Doshi CM, Mohite SN, Dhande AV. Undiagnosed bladder pheochromocytoma: An anesthetic challenge. J Anaesthesiol Clin Pharmacol 2013;29:574-6

How to cite this URL:
Khatavkar SS, Raje DM, Doshi CM, Mohite SN, Dhande AV. Undiagnosed bladder pheochromocytoma: An anesthetic challenge. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2019 Apr 20];29:574-6. Available from: http://www.joacp.org/text.asp?2013/29/4/574/119165

Sir,

Pheochromocytoma is tumor of chromaffin cells derived from embryonic neural crest cells [1] usually in adrenal medulla. Approximately, 10% of these tumors occur at extra adrenal sites and are known as paraganglioma.

Paraganglioma of urinary bladder are rare, 0.05% of all bladder neoplasms. [2] These tumors in bladder cause a characteristic symptom complex most commonly related to micturition due to catecholamine release like paroxysmal hypertension, headache, sweating, palpitations and hematuria. [3] We present a case of bladder paraganglioma without typical symptoms.

A 29-year-old female 60 kg was posted for transurethral bladder tumor resection (TURBT). She presented with painless hematuria and burning micturition since 3 months. On examination, vitals and all routine investigations were normal except urine (routine) which showed red blood cells. Ultrasonography abdomen showed a polypoidal solid lesion arising from right lateral wall of bladder. Cystoscopy revealed a 3-5 cm solid rounded vascular mass arising from bladder base and right lateral wall with stalk [Figure 1].
Figure 1: Ultrasonography view of tumor

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General anesthesia was preferred to avoid obturator spasm occurring under spinal anesthesia. After informed consent, monitors were attached. Heart rate - 90/min, non-invasive blood pressure - 130/80 mmHg, SpO 2-1 00%. Electrocardiogram (ECG) was normal. Intravenous (IV) cannula no. 20 inserted and ringer lactate started. Premedication consisted of injection ondansetron 4 mg, glycopyrolate 0.2 mg, fentanyl 60 g and midazolam 1 mg. Anesthesia was induced with injection. Thiopentone sodium 200 mg slowly followed by injection succinylcholine 75 mg IV to facilitate endotracheal intubation by 7.5 mm cuffed endotracheal tube. Maintenance with O 2 :N 2 O ratio of 50:50 and isoflurane 1% and vecuronium on closed circuit [Figure 2].
Figure 2: Cystoscopic view of tumor

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As tumor biopsy was being taken cystoscopically pulse rate rose to 160/min and blood pressure shot 220/130 mmHg, so anesthesia was deepened with injection fentanyl 50 g IV and isoflurane increased up to 2%, injection xylocard 40 mg, injection metoprolol 3 mg IV slowly, injection nitroglycerine (25 mg in 50 ml) started at rate 0.5 ml/h [Table 1]. The procedure was abandoned. At that moment SpO 2 decreased to 90%, with tightness in reservoir bag. On auscultation air entry reduced, fine crepitations++, pink frothy secretions were present, so endotracheal suction carried out. Patient was ventilated with FiO 2 100% and positive end-expiratory pressure (PEEP). Injection frusemide IV (120 mg), injection hydrocortisone 200 mg, injection dexamethasone 8 mg was given. Air entry improved and pulmonary edema subsided in 30 min. Patient was shifted on ventilator with FiO 2 of 60% on pressure control mode with PEEP to intensive care unit and extubated next day.
Table 1: Recorded vital readings


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Due to this episode high degree of suspicion of pheochromocytoma was kept in mind. Patient was asked about history of fainting attacks during micturition, headache, sweating, visual disturbances, which were absent. Computed tomography scan abdomen/pelvis, ECG 2D echo were normal. Biochemical tests - Metanephrine, adrenaline, urinary vanillylmandelic acid levels were normal. Metaiodobenzyl guanidine (MIBG) showed an abnormal uptake in bladder. Fundus-grade II hypertensive retinopathy. Histopathology of tumor reported paraganglioma of bladder [Figure 3].
Figure 3: Histopathology of tumor

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After 3 months partial cystectomy was done under general anesthesia. Intra-operative arterial line and central venous pressure line were cannulated to measure beat to beat variations of pulse and blood pressure. Vasodilators (injection nitroglycerin) was started to control surge of blood pressure and stopped after tumor excision. Patient was extubated uneventfully.

Pheochromocytoma is a rare catecholamine producing tumor occurring in approximately 0.002% of general population. 0.1% of hypertensive patient have pheochromocytoma which secrete epinephrine, norepinephrine and dopamine. Handling such tumors can precipitate "vascular crisis," so intra-operative hypertension, tachycardia, sweating in absence of any obvious cause should alert possibility of missed neural crest tumor. [4] During TURBT, general anesthesia was given to avoid obturator spasm. Obturator spasm can be avoided under spinal anesthesia by supplementing obturator nerve block. Pre-operative alpha blockers and volume expansion decreases perioperative mortality and morbidity in symptomatic patients. MIBG scanning is specific investigation for diagnosis of paraganglioma. [5] It is an individual and institutional practice regarding choice of alpha adrenergic blockers for pre-operative control of pheochromocytoma. [6] Recently, according to the studies in asymptomatic patient use of alpha blockers before surgery is no longer required, due to advances in anesthetic monitoring and short acting drugs.

Undiagnosed case of pheochromocytoma posted for incidental surgery may cause hypertensive crisis and catastrophic events while diagnosed case can be managed successfully by pre-operative optimization, invasive monitoring and cascade of drugs.



 
  References Top

1.Alderazi Y, Yeh MW, Robinson BG, Benn DE, Sywak MS, Learoyd DL, et al. Phaeochromocytoma: Current concepts. Med J Aust 2005;183:201-4.  Back to cited text no. 1
    
2.Dahm P, Gschwend JE. Malignant non-urothelial neoplasms of the urinary bladder: A review. Eur Urol 2003;44:672-81.  Back to cited text no. 2
    
3.Onishi T, Sakata Y, Yonemura S, Sugimura Y. Pheochromocytoma of the urinary bladder without typical symptoms. Int J Urol 2003;10:398-400.  Back to cited text no. 3
    
4.Hull CJ, Batchelor AM. Anaesthetic management of patients with endocrine disease. In: Thomas EJ, Healy E, Paul RK, editors. A Practice of Anaesthesia. 7 th ed. London: Arnold Wylieand Churchill-Davidsons; 2003. p. 819-20.  Back to cited text no. 4
    
5.Purandare NC, Sanghvi DA, Jhambekar NA. Pheochromocytoma of the urinary bladder. J Ultrasound Med 2005;24:881-3.  Back to cited text no. 5
    
6.Bajwa SS, Bajwa SK. Implications and considerations during pheochromocytoma resection: A challenge to the anesthesiologist. Indian J Endocrinol Metab 2011;15 Suppl 4:S337-44.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
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