Laparoscopic Surgery for Pheochromocytoma

European Urology

European Urology 45 (2004) 226–232

Laparoscopic Surgery for Pheochromocytoma Marcos Fla´vio Rochaa, Rozbeh Faramarzi-Roquesa, Patrick Tauzin-Finb, Vincent Valleea, Paulo R. Leitao de Vasconcelosc, Philippe Ballangera,* a Department of Urology, Hoˆpital Pellegrin-Tondu, Centre Hospitalier Universitaire Pellegrin, 5 place Ame´lie Raba-Le´on, 33076 Bordeaux Cedex, France b Department of Anesthesiology III, Hoˆpital du Tondu, Centre Hospitalier Universitaire Pellegrin, Bordeaux, France c Department of Urology, Universite´ Fe´de´rale du Ceara, Fortaleza, Brazil

Accepted 17 September 2003 Published online 10 October 2003

Abstract Objective: To evaluate the feasibility of laparoscopic adrenalectomy for pheochromocytoma. Material: Between January 1998 and March 2002, 12 patients aged from 19 to 76 (average age 54 years) underwent 13 adrenalectomies (7 right and 6 left, 1 bilateral) using laparoscopic surgery. A specific anti-hypertensive preparation was begun prior to the operation. Peaks of blood pressure were treated by bolus Nicardipine and sinus tachycardia by bolus Esmolol. Catecholamines were dosed at different times during the intervention. As far as surgery was concerned, the adrenalectomies were performed 11 times using the transperitoneal route and twice using the retroperitoneal route. The adrenal vein was found and ligatured before manipulation of the adrenal gland. Results: Average length of operation was 127 minutes (75 to 195). Average blood loss was 105 ml (0 to 1000). Catecholamines dosed throughout showed a variable increase in plasma rates during peritoneal insufflation and manipulation of the gland. They were responsible for 5 cases of hypertensive bouts and 2 cases of tachycardia which were treated with medication. No surgical conversions were necessary. Average length of hospital stay was 4.18 days (3 to 6); average size of adrenal tumours was 44 mm (30 to 72); average follow-up, 18.4 months. Conclusion: This study showed the feasibility of adrenalectomy for pheochromocytoma using laparoscopic surgery, subject to specific medical preparation to reduce the consequences of peroperative bouts of hypertension and sinus tachycardia during peritoneal insufflation and manipulation of the adrenal gland despite initial ligature of the main adrenal vein. # 2003 Elsevier B.V. All rights reserved. Keywords: Pheochromocytoma; Laparoscopy; Catecholamines

1. Introduction The ultimate treatment for pheochromocytoma consists in the surgical removal of the adrenal glands and/ or paragangliomas. Before the 1950s surgical mortality rates were between 20% and 50% [1]. Absence of *

Corresponding author. Tel. þ33-556-79-56-79; Fax: þ33-556-79-56-86. E-mail address: [email protected] (P. Ballanger).

adequate monitoring of hypertensive attacks and cardiac arrhythmias during manipulation and removal of the pheochromocytoma were responsible for this high mortality rate. Advances in peroperative monitoring and the introduction of preoperative blocking of a1 receptors has since radically reduced the mortality rate. The adrenal gland is situated deep in the retroperitonium, near the diaphragm. Surgical access routes, such as the anterior transperitoneal route, the posterior, or lumbar route are difficult, and associated with high morbidity and lengthy convalescence [2].

0302-2838/$ – see front matter # 2003 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2003.09.016

M. Fla´ vio Rocha et al. / European Urology 45 (2004) 226–232

The first laparoscopic adrenalectomies were reported by Gagner et al. and Higashihara et al. in 1992 [3–5]. Numerous studies have shown that adrenalectomies using the laparoscopic approach offered reduced morbidity compared with open surgery [6–8]. Laparoscopic techniques became standard for treatment of tumours of the adrenal glands [9–11]. However, there are still doubts and uncertainties concerning the use of laparoscopy in the treatment of pheochromocytoma, in particular as regards cardiovascular risks in comparison with conventional surgery. These risks are connected with the liberation of catecholamines. Factors such as the use of carbon dioxide, increase in abdominal pressure and manipulation of the adrenal gland are known to cause additional releases of plasma catecholamines. However, a number of series of laparoscopic adrenalectomies using the transperitoneal or retroperitoneal route in the treatment of pheochromocytoma have been reported with good results [12–17]. The object of the present study is to report our experience with particular emphasis on cardiovascular safety while studying preoperative catecholamine secretion during laparascopic adrenalectomy for treatment of pheochromocytoma. We also underline the main points, from both surgical and anaesthetic perspectives, which govern the success of this operating technique. Finally we indicate the repercussions of this type of operation on catecholamine secretion.

2. Material and methods 2.1. Material From January 1998 to March 2002, 12 consecutive patients (8 women, 4 men) underwent 13 adrenalectomies for pheochromocytoma (7 right and 6 left) in our department. In one case, the adrenalectomy was bilateral during the same operative session. The age of patients varied from 19 to 76 (average age: 54 years). Body mass index was between 20.91 and 27.94 (average BMI: 24.26). 10 patients suffered from catecholamine hypersecretion manifested by high blood pressure (HBP). In one patient the discovery was fortuitous and another presented an associated disorder (NEM type 2). Circumstances of discovery are indicated in Table 1. The diagnosis of pheochromocytoma was confirmed systematically by testing plasma catecholamines and urinary methoxylated derivates (all patients suffered from catecholamine hypersecretion). A CT scan of the abdomen and pelvic region, and/or an MRI scan and scintigraphy using MIBG gave the precise location. In our series we found 13 adrenal tumours from 30 to 72 mm in size (average size: 44 mm). As far as medical history was concerned, one patient had undergone surgery for partial removal of the pancreas and another a right hemicolectomy. 2.2. Method Patients were studied prospectively and data collected from case files as well as a computerized data base.

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Table 1 Circumstances of discovery Patient

HBP

Headaches

Sweating

Palpitation

Other

1 2 3 4 5

0 þ þ þ þ

0 0 0 0 þ

0 þ 0 0 þ

0 0 0 0 0

6 7

þ þ

0 0

0 0

0 0

8 9 10

þ 0 þ

0 0 þ

0 0 þ

0 0 þ

11 12

þ þ

0 þ

0 þ

0 0

NEM type 2 NEM type 1 0 0 Prinzmetal, pallor 0 Sd Beckwith Wiedeman 0 Incidentaloma Pallor, flush, APO 0 0

Length of operation was defined as being the time between the first incision made in the skin and the closing of all incisions. Length of hospital stay was defined as being the length of postoperative stay in the department. Complications were classed using Clavien’s system [18]. All patients underwent a pre-operative cardiovascular assessment consisting of a Doppler echocardiography and Holter monitoring over 24 hours. Medical preparation began 15 days prior to surgery consisting of one slow release alpha-blocker (Prazosine (alpress1) LP 5 mg/day) and one beta-blocker (Bisoprolol (detensiel1) 10–20 mg/day). Three days prior to surgery, one alphablocker with a short half-life was substituted for the oral medication and maintained up to the end of the operation at a dose of 250 mg/ day in continuous perfusion with hourly monitoring of blood pressure by sphygmomanometer. Oral premedication consisted of 5 mg of Midazolam and 0.5 mg of Atropine. The general anaesthetic was standardised as follows: induction using intravenous Propofol and Sufentanil according to blood pressure (BP) levels as measured by oscillometer, and orotracheal intubation facilitated by Cisatracurium; continuous perfusion of Sufentanil and Cisatracurium maintained during operation as well as administration of Sevoflurane in 100% oxygen, the final fraction of Sevoflurane being maintained at 2–2.5% in a closed circuit by Cato respirator. Ventilation was adapted to maintain PET CO2 between 35 and 45 mmHg. Urapidil was maintained at a continuous flow of 10–15 mg/hour up to clamping of the adrenal veins. Peaks of pressure defined by systolic arterial pressure (SAP) higher than 160 mmHg were treated using bolus doses of Nicardipine so as to maintain SAP between 120 and 160 mmHg. Episodes of sinus tachycardia, defined by a heart beat of more than 120 b min1 were treated by bolus Esmolol. Blood samples to dose catecholamines using high performance liquid chromatography were carried out at the following times: t0: test just before induction; t1: after the induction, laryngoscopy, intubation sequence; t2: during peritoneal insufflation; t3: during manipulation-extraction of pheochromocytoma; t4: after removal of pheochromocytoma; t5: in the recovery room, patient extubated and hemodynamically stable. As far as surgery goes, the stages were as follows: a bladder catheter was placed; the patient was placed in the lateral decubitus position on the side opposite to the lesion, on two posterior supports, sacral and thoracic. The support areas were protected by gelose, in particular the external popliteal plexus and the

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brachial plexus. The lumbar fossa was opened by placing a block under the patient. The operating table was inclined to obtain a 458 lateral decubitus position. The operator stood facing the abdomen with his assistant between him and the anaesthetist at the patient’s head. The monitor was situated opposite on a level with the patient’s shoulders. For a left adrenalectomy, four trocars were placed 3 finger widths below the costal margin from the 11th rib to the xyphoide process. The first 10 mm trocar was placed using open laparoscopy, and a 12 mmHg pneumoperitonium created. The other trocars were placed under visual control. The lateral peritoneal reflection (line of Toldt) was incised thus reflecting the colon medially. The spleen was retracted upwards and inwards after section of the splenocolic ligament, exposing the upper pole of the left kidney through Gerota’s fascia. The left renal vein was dissected, the adrenal vein was then found and sectioned between clips. Next, the adrenal gland was dissected in the adrenal fossa. The auxilliary adrenal veins and arteries were then sectioned between clips or after coagulation with bipolar forceps. The resected adrenal gland was withdrawn in a size 10 EndobagTM through the 10 mm trocar opening after the orifice had been enlarged by 1 cm either side. An aspirating drain was placed in the site after hemostasis had been checked. Exsufflation was carried out and the trocar openings closed in two layers. In the case of right adrenalectomies, the same anatomical markers as for the left side were used for insertion of the trocars. The right lobe of the liver was reclined inwards by the EndopalmTM after section of the triangular ligament. The kidney fossa was exposed above the right angle of the colon. The vena cava was dissected, the adrenal vein exposed and sectioned between clips. The remainder of the operation was identical to that for right adrenalectomies. We carried out adrenalectomies using the retroperitoneal route in two patients who had a prior history of significant homolateral abdominal surgery. The operations were carried using the techniques described by the Abbou team [19]. As far as the post-operative period was concerned, food intake took place once return of intestinal transit had occurred, the drain was removed once it was dry, perfusions were removed after food intake had started and pain had subsided. Patient controlled analgesia was used postoperatively, principally Tramadol (OMS II) relayed by Paracetamol per os. Rapid ambulation was encouraged and the patient was discharged once independent.

3. Results The same surgeon carried out 13 adrenalectomies, 7 right and 6 left. Eleven were carried out using the transperitoneal route and two using the retroperitoneal route. As for the bilateral pheochromocytoma, the transperitoneal route was used for the right and retroperitoneal for the left in the same anesthetic time. 10 patients were ASA II and 2 ASA III. Blood pressure (lower than 150/90 mmHg) and heart rate (lower than 100 b min1) were stabilised using Urapidil. Preoperative assessments showed no anomalies (left venticle ejection fraction higher than 60%). No conversion was necessary. Mean operative time was 127 minutes (from 75 to 195 min). Peroperative

blood loss was between 0 and 1000 ml with an average of 105 ml. Heavy bleeding (1 litre) occurred in only one case, where a tear of the adrenal vein treated during laparoscopy, and transfusion was required. Three patients presented hypercapnia of respectively 60, 52 and 49 mmHg, rapidly corrected by a change in respirator parameters. There was no subcutaneous emphysema. In the post-operative period, one patient presented hyperthermia on the second day (D2) after the operation, resolved with antibiotics. No other complications were noted. Postoperative pain was treated successfully through PCA, using Tramadol, 300– 350 mg per day. A 500 mg paracetamol relay was used three times a day for 24 to 48 hours as pain diminished and bowel movement resumed. Food intake took place between days D1 and D3. The drains were removed between days D2 and D3. Ambulation was authorised between the first and third days, with an average of 2.18 days. Discharge occurred between days D3 and D6: average hospital stay was 4.18 days. Dosages of plasma catecholamines available for 11 patients are indicated in Tables 2 and 3. High concentrations were found during peritoneal insufflation and during the manipulation and surgical removal of the tumour, with great variability in individual patients and between patients. Bouts of hypertension were observed in 5 cases during peritoneal insufflation, associated in two cases with bouts of sinus tachycardia. Manipulation and surgical removal of the tumour resulted in 8 peaks of hypertension, associated in 2 cases with bouts of sinus tachycardia in spite of initial ligation of the adrenal vein. After the tumour was removed, 4 transient collapsus Table 2 Dosage of plasma noradrenaline at different times during the operation in pg/ml (normal value <510 pg/ml) Patient

t0

t1

t2

t3

t4

t5

1 2 3 4 5 6 7 (pheo R) 7 (pheo L) 8 9 10 11 12

2344 802 1013 – 3705 5893 8442

5157 623 3215 – 4169 12455 23262 2074 7183 555 1138 1011

20449 26735 14999 – 115871 31271 78990 36915 38351 101233 71834 4137 11426

2887 5023 4571 – 24916 15912 42164 3895 5356 10105 5061 2574 6816

1413 3306 1071 – 3293 3137

1936 5459 605 2860 1712

11920 7372 7147 – 321735 24011 44278 17249 7975 11357 7469 1871 22417

2080 2373 2083 1331 2060 5900

t0: monitoring just before induction. t1: after induction, laryngoscopy, intubation sequence. t2: during peritoneal insufflation. t3: during manipulation-extraction of pheochromocytoma. t4: after removal of pheochromocytoma. t5: in post-operative intensive care, patient extubated and hemodynamically stable.

M. Fla´ vio Rocha et al. / European Urology 45 (2004) 226–232 Table 3 Dosage of plasma adrenaline at different times during the operation in pg/ ml (normal value <170 pg/ml) Patient

t0

t1

t2

t3

t4

t5

1 2 3 4 5 6 7 (pheo R) 7 (pheo L) 8 9 10 11 12

665 512 199 – 3190 1253 91

2550 470 852 – 37434 3195 122 55 270 792 228 381

17320 32935 5761 – 103153 10398 3044 300 3420 2894 142444 280 8785

1645 4358 1362 – 11208 6941 552 113 186 377 9531 210 4918

1131 3123 360 – 1293 1139

72 326 619 – 455

9581 8406 2411 – 203279 4960 254 160 630 561 10199 230 18921

110 182 934 1173 – 3170

t0: monitoring just before induction. t1: after induction, laryngoscopy, intubation sequence. t2: during peritoneal insufflation. t3: during manipulation-extraction of pheochromocytoma. t4: after removal of pheochromocytoma. t5: in post-operative intensive care, patient extubated and hemodynamically stable.

were observed in 12 of the patients out of the 13 surgical removals. Anti-hypertensive treatment was stopped before the patients left hospital. The average size of the adrenal tumours was 44 mm (30–72 mm). Histological examination confirmed the diagnosis of pheochromocytoma for all the tumours and there was one malignant pheochromocytoma in the series due to the presence of vascular emboli and invasion of the capsule. The preoperative scan and MRI showed a heterogenous mass between 6 and 7 cm, partly necrotised, and the absence of locoregional invasion of the lymph node and of metastases. This patient has a 13 month follow-up with no sign of metastases or recurrence. Average follow-up of all patients was 18.4 months. At 6 months, patients had an acceptable abdominal scar and were no longer on medication.

4. Discussion Despite the absence of randomized prospective studies comparing laparoscopic adrenalectomies to open adrenalectomies, the results of retrospective studies are in favour of laparoscopic surgery. This technique has become the standard technique for treatment of adrenal tumours [6–11]. The laparoscopic technique has a number of advantages over open surgery: post operative pain is considerably lessened, ambulation is rapid, hospital stay is shorter and a return to normal activity is much more rapid [5,6,10]. But surgery for pheochromocytoma does differ from that of other adrenal gland

229

tumours because of increased cardiovascular risks during the operation due to the release of catecholamines [2,12]. Pheochromocytomas are neuro-endocrinal tumours which secrete a chronic exess of catecholamines resulting in hypertension, contraction of plasmatic volume due to permanent vasoconstriction and, occasionally, adrenergenic myocardiopathy [20]. The use of laparoscopy in cases of pheochromocytoma is controversial because of the increase in abdominal pressure during surgery which leads to hemodynamic changes and a risk of additional release of catecholamines [21–24]. Our study confirms that peritoneal insufflation is accompanied by a significant release of plasma catecholamines. Peritoneal insufflation is associated with an increase in plasma catecholamines whether the stimulus be mechanical compression, or a change in tumour vascularisation [25,26]. Furthermore, CO2 can lead to hypercapnia and respiratory acidosis responsible for bouts of hypertension. Helium has been suggested so as to remove the potential role of hypercapnia [27]. Joris observed an increase in plasma concentrations of catecholamines after peritoneal insufflation and during manipulation of the adrenal gland [23]. Our study also showed that manipulation of pheochromocytoma during laparoscopic surgery led to an increased release of catecholamines, in spite of initial ligation of the adrenal vein. However, Fernandez-Cruz has reported that laparoscopic adrenalectomy of pheochromocytoma was associated with a lower increase in the rate of catecholamines in peripheral circulation than in open surgery and that hypertensive bouts were connected with direct manipulation of the adrenal gland [17]. From this study it would appear that there is a similar increase in catecholamines during insuflation in both celioscopy and laparotomy. However catecholamine rates increase twice as much during manipulation of the adrenal gland during open surgery ( p < 0:03). Despite a significant increase in the rates of plasma norepinephrine and epinephrine related to peritoneal insufflation and mobilisation of the adrenal gland, the adrenalectomies were carried out with a low rate of morbidity. The surgical removal of pheochromocytoma can be carried out using laparoscopic techniques, but this requires careful preoperative preparation and attentive peroperative monitoring by the anaesthetist watching for hypertensive attacks and occasional cardiac arrythmia. The object of preoperative medical preparation is to reduce cardiovascular morbidity and includes alpha-blockers and eventually betablockers. The hypertensive attacks caused by pheochromocytoma are connected with the stimulation of a1

M. Fla´ vio Rocha et al. / European Urology 45 (2004) 226–232

230

receptors [21]. In our series, preoperative monitoring of blood pressure was obtained by blocking the a1 receptors with Urapidil. The b adrenergic blocker is not systematically given and depends on whether the patient has associated tachycardia or not [21]. During surgery, two problems co-exist with two opposing solutions: on the one hand release of catecholamines during manipulation of the adrenal gland induces a risk of paroxysmal hypertension and bouts of sinus tachycardia, which can be effectively treated by associating Nicardipine (a calcium channel blocker) and Esmolol (b adrenergic blocking agent). On the other hand, the sudden release of catecholamine during surgical removal of the tumour can induce collapsus which the persisting effectiveness of a1 blockers given in the preoperative period can worsen [21]. It is for this reason that we used an a1 blocker, in injectable form, with a shorter half life in the peroperative phase. One surgical element essential to preventing any hypertensive attacks is the ligature of the adrenal vein before dissection of the adrenal gland [20,30], though our data does not confirm this opinion. Laparoscopic adrenalectomies have been described using both the transperitoneal route and the retroperitoneal route [3,7,8,12,15,16,31–33]. Most of the adrenalectomies for pheochromocytoma described in the literature were carried out using the transperitoneal route [12,15,24]. Janetschek, in one series of adrenalectomies comprising 19 patients reported a length of operation of 150 minutes, an average blood loss of 130 ml and an average hospital stay of 4.9 days. He argues that the transperitoneal route permits direct access to the adrenal vein with less risk of hypertensive attacks. In addition, this approach offers another benefit, the possibility of treating bilateral pheochromocytomas and extra-adrenal pheochromocytoma [15]. On the other hand, for Abbou’s team, the retroperitoneal route permits inspection and ligature of the adrenal vein before any manipulation of the gland. This retroperito-

neal route was used by them in a series of 10 adrenalectomies for pheochromocytoma. Length of operation was 116 minutes, average blood loss 180 ml, and average hospital stay 3.4 hours. He argues that on the right side, the inferior vena cava is the first marker, the renal pedicle the second, and the adrenal vein is then to be found above it. On the left side, the adrenal vein is to be found between the renal vein and the renal artery. In addition, he considers that the development of more precise and less invasive diagnostic imaging methods will enable precise location of extra adrenal pheochromocytomas and avoid the necessity of exploring the whole of the abdominal cavity [2]. In our series, 11 adrenalectomies were carried out using the transperitoneal route and 2 by the retroperitoneal route. We believe that the transperitoneal approach enables inspection and ligature of the adrenal vein without dissection of the gland. This possibility is particularly interesting in the case of pheochromocytomas. However, because of their previous intraperitoneal surgical history (partial pancreatectomy and right colectomy) we decided to use the retroperitoneal route for two patients. So, it would appear necessary to be able to master both approaches and to then make the choice according to specificities of the patient and his pathology. The low morbidity rate in our series was comparable to the data in the literature. In the published data, no significant difference in morbidity was found between the series where the transperitoneal route was used and those using the retroperitoneal route [2,15,17,28,29] (Table 4). Pheochromocytomas are malignant in 10% of cases [34]. As yet, there is not any significant experience in using laparoscopic techniques in cases of adrenal carcinoma. Unfortunately, it is not always possible to establish at the preoperative stage whether there is primary malignacy or not. Further more, it is not possible to forecast how the disease will develop, even

Table 4 Review of the literature Number

Approach

Length of operation

Fernandez-Cruz [17] 1996 8 Janetschek [15] 1998 19 Bonjer [28] 1998 8 Mo¨ bius [29] 1999 10 Abbou [2] 2001 10

Trans. Trans. Retro. Trans. Retro.

127 203 150 (90–240) 130 (0–300) 90 20 243 (125–360) – 116 (100–140) 180 (0–550)

Our series 2002

Trans. (11) Retro. (2)

127 (75–195)

13

Laparoscopic adrenalectomies for pheochromocytoma.

Blood loss (ml)

Size of tumour (cm)

Length of Conversion hospital stay (%)

Complication (%)

4.1 5.7 (1–8) 3 3.8 (1.7–7.5) 3.8 (1.5–7)

4 4.9 (3–7) 4 6 (4–19) 3.4 (1–12)

– 1 (7.1%) – 1 (10%) 1 (10%)

4.1 (3–6)

–

– – – 1 (10%), transfusion 2 (20%), hematoma, eventration 2 (15.3%), fever, transfusion

105 (0–1000) 4.4 (3–7.2)

M. Fla´ vio Rocha et al. / European Urology 45 (2004) 226–232

in the case of favorable histological reports at the beginning [5]. The traditional concept of explaining tumours under 6 cm as being benign is no longer thought correct. But it would appear that for most adrenal glands with tumours under 6 cm which are operated (1500 cases in the literature) development of metastases is rare [5].

5. Conclusion Our data confirm previous studies showing the feasibility of laparoscopic adrenalectomy for pheochromocytoma using either retro or transperitoneal approach with a low morbidity. It is therefore important to master the use of both approaches, retroperitoneal

231

and transperitoneal, to then make the choice according to specificities of the patient and the pathology. We noted a significant increase in the rate of plasma catecholamines during peritoneal insufflation and manipulation of the adrenal gland despite initial ligature of the main adrenal vein. Surgeons must be aware of this risk of a rise of plasma cathecolamines concentration after ligation of the adrenal vein. Further larger studies would be interestingly conducted in order to analyse predictive factors of catecholamine discharge according to different parameters: size, localization (right or left) and length of operation. However, one of the principal points of this study lies in the development of the pharmacological aspects, meaning that clinical repercussions can be minimised despite catecholamine discharge and that surgery is therefore safer.

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