From the Guidelines
The surgical approach to pheochromocytoma removal typically involves laparoscopic adrenalectomy as the preferred method, though open surgery may be necessary for larger tumors or those with suspected malignancy. This approach is supported by the most recent and highest quality study, which emphasizes the importance of complete resection and the role of laparoscopic adrenalectomy in selected patients 1.
Key Considerations
- Preoperative preparation is crucial and includes alpha-adrenergic blockade with phenoxybenzamine for 1-2 weeks before surgery, followed by beta-blockade only after adequate alpha-blockade is established.
- Patients should also receive volume expansion with intravenous fluids and a high-sodium diet preoperatively to prevent severe hypotension after tumor removal.
- During surgery, the adrenal vein should be ligated early to prevent catecholamine release into circulation, and the surgeon should minimize tumor manipulation to avoid dangerous catecholamine surges.
- Intraoperatively, the anesthesiologist must be prepared to manage hemodynamic instability with short-acting agents like sodium nitroprusside for hypertension and norepinephrine for hypotension.
Postoperative Care
- After surgery, patients require close monitoring for hypoglycemia and hypotension, as these are common complications following tumor removal.
- Complete resection is essential, and if bilateral pheochromocytomas are present, cortical-sparing techniques should be considered to preserve adrenal function when possible.
- The recent ESMO-EURACAN clinical practice guidelines for diagnosis, treatment, and follow-up of adrenocortical carcinomas and malignant pheochromocytomas support this approach, emphasizing the importance of surgery in the treatment of both conditions 1.
Evidence-Based Recommendations
- The guidelines recommend that adrenal surgery should be carried out only by surgeons with appropriate expertise and experience, and that the entire operative team should be well-trained in adrenal surgery 1.
- The use of laparoscopic adrenalectomy is recommended for tumors <6 cm without evidence of local invasion, and open surgery is recommended for larger tumors or those with suspected malignancy 1.
- The guidelines also emphasize the importance of preoperative preparation, including alpha-adrenergic blockade and volume expansion, and the need for close monitoring of patients postoperatively 1.
From the Research
Surgical Approach to Pheochromocytoma Removal
The surgical approach to removing pheochromocytomas has evolved over the years, with laparoscopic adrenalectomy becoming a preferred method due to its minimally invasive nature and faster recovery times 2, 3, 4.
Key Considerations
- Preoperative medication with alpha 1 blockers is crucial to prevent excessive hypertension or hypotension during surgery 2.
- Early ligation of the adrenal vein and minimal handling of the tumor are also important considerations 2.
- The transperitoneal approach is preferred by most surgeons, although the retroperitoneal approach can also be used successfully 2.
Comparison of Laparoscopic and Open Adrenalectomy
- Laparoscopic adrenalectomy has been shown to have similar or better perioperative outcomes compared to open adrenalectomy, including shorter operative times, less blood loss, and shorter hospital stays 2, 3, 5.
- However, laparoscopic adrenalectomy may require more experience and skill to perform safely, especially for larger tumors 3, 6.
Tumor Size and Surgical Outcome
- The size of the tumor does not appear to have a significant impact on surgical outcome, as long as there is no evidence of invasion of surrounding structures 3, 6.
- However, larger tumors may be associated with a higher conversion rate to open surgery and more intraoperative hypertensive crises 6.
Safety and Feasibility of Laparoscopic Adrenalectomy
- Laparoscopic adrenalectomy is considered a safe and effective approach for removing pheochromocytomas, with low morbidity and mortality rates 4, 6, 5.
- Preoperative selective adrenergic blockade can help manage perioperative hemodynamic instability, but may not prevent intraoperative hypertensive crises 6.