Elsevier

Urology

Volume 100, February 2017, Pages 131-138
Urology

Oncology
Preoperative Levels of Catecholamines and Metanephrines and Intraoperative Hemodynamics of Patients Undergoing Pheochromocytoma and Paraganglioma Resection

https://doi.org/10.1016/j.urology.2016.10.012Get rights and content

Objective

To determine whether, despite pharmacologic adrenergic receptor blockade, higher preoperative levels of catecholamines and metanephrines (adrenergic activity) are associated with increased intraoperative complications.

Materials and Methods

Records of patients undergoing paraganglioma and pheochromocytoma (PGL-PCC) resection from January 1, 2000, to June 30, 2015, were reviewed for preoperative levels of adrenergic activity, intraoperative variability in blood pressure and heart rate (range), and postoperative outcomes (hypotension requiring treatment). Patients were categorized by maximum preoperative adrenergic activity by greater degree of abnormality, categorized as normal (≤100%) or 101%-200%, 201%-500%, 501%-1000%, and ≥1001% of upper limit of normal.

Results

In total, 258 patients underwent intrathoracic or intra-abdominal PGL-PCC resection, of whom 240 received pretreatment with nonselective α1,2-blockers and 7 received pretreatment with selective α1-blockers. Intraoperative hemodynamic variability was greater with higher preoperative levels of adrenergic activity (P <.001). However, substantial variability was observed even with adrenergic activity levels within the normal range: systolic blood pressure (median [interquartile range], 75 [63-83] mm Hg) and heart rate (34 [26-43] beats per minute). Among patients with preoperative levels of adrenergic activity ≤500% vs ≥501% of the upper limit of normal, higher levels were associated with greater likelihood of postoperative diagnosis of volume overload (8% vs 2%, P = .04) and greater requirement for vasopressor infusions for hypotension (5% vs 1%, P = .01).

Conclusion

Substantial intraoperative hemodynamic instability was encountered in patients with PGL-PCC resection, regardless of preoperative hormonal activity level; therefore, universal preoperative adrenergic receptor blockade should be recommended. Postoperative hypotension was rare and more prevalent in those with higher preoperative hormonal activity.

Section snippets

Materials and Methods

The Mayo Clinic Institutional Review Board approved this study. In accordance with Minnesota State Statute 144.335, we included only the patients who provided authorization for research use of their medical records.

Results

Between January 1, 2000, and June 30, 2015, a total of 258 patients with abdominal, pelvic, or thoracic PGL or PCC underwent surgical resection. Patients presented with 48 PGLs and 210 PCCs, of which 49 were resected through open surgical approach and 161 were resected laparoscopically. Table 1 summarizes preoperative demographic characteristics, comorbidities, and relevant preoperative therapies used to prepare patients for surgery. Pharmacologic treatment was administered to 254 patients

Discussion

We determined that patients undergoing PGL-PCC resection have substantial intraoperative hemodynamic oscillations regardless of their preoperative adrenergic activity. Oscillations were more pronounced when preoperative adrenergic activity was more than 2-fold greater than the upper limit of the reference range. Despite the fact that most of our patients were pretreated with PBZ, postoperative hypotension requiring treatment was rare but was more frequent in patients with higher adrenergic

Conclusion

Despite universal preoperative pharmacologic preparation of patients undergoing PGL-PCC resection, substantial hemodynamic variability was present intraoperatively, even in patients with normal or mildly elevated levels of preoperative adrenergic activity. Therefore, we suggest that all patients undergoing thoracic, abdominal, and pelvic PGL-PCC resection should be appropriately prepared with α-adrenergic blockade, regardless of degree of tumoral secretion of catecholamines and metanephrines. A

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Financial Disclosure: The authors declare that they have no relevant financial interests.

Funding Support: Support was provided by the Department of Anesthesiology, Mayo Clinic, Rochester, MN.

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