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Laparoscopic management of bladder pheochromocytoma
CASE REPORTS
LAPAROSCOPIC MANAGEMENT OF BLADDER PHEOCHROMOCYTOMA PAUL M. KOZLOWSKI, FREDRICK MIHM,
AND
HOWARD N. WINFIELD
ABSTRACT Pheochromocytoma primarily involving the bladder is an uncommon pathologic finding. Patients may present with transient hypertension associated with palpitations and diaphoresis on micturition. A case of bladder pheochromocytoma treated by laparoscopic partial cystectomy is presented. The management principles of bladder pheochromocytoma for our specific case are discussed. Successful treatment requires that the correct diagnosis and tumor location be made in conjunction with the obligatory preoperative preparation of the patient. UROLOGY 57: 365v–365vii, 2001. © 2001, Elsevier Science Inc.
A
21-year-old woman presented to her primary care provider with a 2-year history of mildly elevated blood pressure. Her hypertension and an elevated 24-hour urine collection for norepinephrine of 751 g/24 hours (normal 15 to 80) were initially attributed to weight-reducing medications. Hypertension persisted despite discontinuation of these drugs. History revealed that the patient reported episodic palpitations, flushing, light-headedness, and diaphoresis, often occurring with micturition. She denied gross hematuria, urgency, or other lower urinary tract symptoms. Her past medical history was significant for anorexia nervosa and depression. Physical examination was normal. Blood pressure reading on initial presentation demonstrated a systolic range of 108 to 177 mm Hg, diastolic range of 50 to 111 mm Hg, and a pulse rate of 78 to 103 while supine. Preoperative testing included plasma and two 24-hour urine collections for catecholamines; results are shown in Table I. Magnetic resonance imaging (MRI) of the abdomen and pelvis revealed a 3.3 ⫻ 3.1-cm soft tissue mass, extending from the left anterolateral aspect of the bladder. The lesion had a slightly increased T2-weighted image and intermediate T1 signal intensity (Fig. 1). No addiFrom the Departments of Urology and Anesthesia, Stanford University, Stanford, California Address for correspondence: Howard N. Winfield, M.D., Department of Urology, Stanford University School of Medicine, 300 Pasteur Drive, S-287, Stanford, CA 94305-5118 Submitted: June 19, 2000, accepted (with revisions): September 11, 2000 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
tional lesions or evidence to support metastases were found on iodine 131-methyliodobenzylguanidine (131I-MIBG) scintigraphy, chest x-ray, and computed tomography (CT) scan. Prior to surgery the patient received phenoxybenzamine titrated up to 30 mg twice daily and labetalol 150 mg twice daily for 28 days. Blood pressure was brought into the normal range. The patient was evaluated for evidence of cardiac complications of pheochromocytoma. Cardiac enzymes, electrocardiogram, and echocardiography (ejection fraction 55%) were normal. Under general anesthesia, initial cystoscopy demonstrated the lobulated tumor to be a sufficient distance from the ipsilateral ureteral orifice for excision. With the use of a four-port (5 to 10 mm) diamond arrangement, at 15° Trendelenburg, pneumoperitoneum was established. The lesion was dissected from the overlying peritoneum and perivesical fat. Switching to cytoscopy, a Collin’s knife was employed to circumferentially excise around the lesion with a 2-cm margin. The laparoscopic Harmonic Shears (Ethicon Endosurgery) completed the excision. The specimen was removed, using a laparoscopic sac. The cystotomy was repaired, using a single layer of 2-0 polyglactin interrupted sutures, placed laparoscopically, using both the EndoStitch device (Autosuture Corp, Norwalk, Conn) and free-hand intracorporeal suturing. Distension of the bladder at the completion of the repair showed no leakage. A 10F JacksonPratt drain was placed in the pelvis and brought out through a lateral trocar site. A 22F Foley catheter was placed transurethrally into the bladder. 0090-4295/01/$20.00 PII S0090-4295(00)00899-2 365v
TABLE I. Results of plasma and 24-hour urine analysis Normal Values Plasma Norepinephrine (pg/mL) Epinephrine (pg/mL) 24-hour urine Epinephrine (g) Norepinephrine (g) Vanillylmandelic acid (mg) Homovanillic acid (mg) Dopamine (g) Metanephrines (g) Normetanephrines (g)
111–498 ⬍50 (supine) ⬍95 (upright) 0–20 15–80 0–7 0–15 60–440 30–350 50–650
Preoperative 5702 ⬍20
1.0 751 11.1 2.1 146 — —
Postoperative — —
5.0 23 3.6 4.8 274 134 339
Final pathology was consistent with pheochromocytoma of the bladder. Because of the absence of metastases, the tumor is believed to be benign. All surgical margins were free of tumor. COMMENT
FIGURE 1. MRI scan pheochromocytoma.
demonstrating
bladder
RESULTS The patient was normotensive following surgery with occasional episodes of hypotension when sitting or standing too quickly in the first few days. Total surgical time, including transurethral circumferential incision and laparoscopic excision of the tumor with bladder reconstruction, was 300 minutes. Estimated blood loss was less than 200 cc. Clear fluids were resumed within 12 hours of the surgery. Total narcotic requirements were higher than expected during her hospitalization: morphine sulfate intravenously 146 mg, ketorolac tromethamine (Toradol) intramuscularly 120 mg; and oxycodone and acetaminophen (Percocet) 9 tablets. Full ambulation occurred by postoperative day 2. All antihypertensive medication was discontinued during the 4-day hospitalization. Cystogram performed at 2 weeks was normal, at which time her Foley catheter was removed. One month following surgery, she was normotensive and denied any of the symptoms that she experienced preoperatively. Her endocrine panel is normal (Table I). 365vi
Pheochromocytoma of the bladder accounts for less than 0.06% of all bladder tumors.1 Although rare, a high clinical suspicion for pheochromocytoma must be maintained for bladder lesions in hypertensive young patients. Preoperative recognition of such lesions is essential to prevent serious complications. Endocrine and radiographic evaluations aid in the diagnosis of pheochromocytoma. Sixty-five percent of bladder pheochromocytomas present with hypertension.2– 4 Hypertensive crises, potentiated by voiding in 47% to 77% of cases, are characterized by migraines, palpitations, blurred vision, and sweating.5 Elevated catecholamines (epinephrine and norepinephrine) and their metabolites (metanephrine and vanillylmandelic acid) strongly suggest the diagnosis of pheochromocytoma. CT scans are widely used for the localization of pheochromocytomas.6 Additional imaging modalities that are especially useful include MRI and 131 I-MIBG scintigraphy. Careful preoperative alpha blockade (phenoxybenzamine) for at least 1 to 2 weeks is required to counteract the effects of released catecholamines. The use of beta blockers should usually be used after the initiation of alpha blockade if tachycardia or arrhythmias occur.7 CONCLUSIONS We report a single case of pheochromocytoma of the bladder managed by laparoscopic partial cystectomy. After careful preoperative biochemical and radiologic evaluation with detailed surgical UROLOGY 57 (2), 2001
preparation, our patient underwent successful laparoscopic partial cystectomy for this lesion. Application of the combined laparoscopic and endoscopic approaches to partial cystectomy is an attractive alternative to traditional open surgery. However, only a larger series and comparison to open surgical excision of such lesions will determine if this minimally invasive procedure should be considered the preferential approach. REFERENCES 1. Leestma JE, and Price EB: Paraganglioma of the urinary bladder. Cancer 28: 1063–1073, 1971. 2. Das S, Bulusu NV, and Lowe P: Primary vesical pheo-
UROLOGY 57 (2), 2001
chromocytoma of the urinary bladder. Urology 21: 20 –25, 1983. 3. Samaan NA, Hickey RC, and Shutts PE: Diagnosis, localization, and management of pheochromocytoma. Cancer 62: 2451–2460, 1988. 4. Gittes RF, and Mahoney EM: Pheochromocytoma. Urol Clin North Am 4: 239 –252, 1977. 5. Sweester PM, Ohl DA, and Thompson NW: Pheochromocytoma of the urinary bladder. Surgery 109: 677– 681, 1991. 6. van Heerden JA, Sheps SB, Hamberger B, et al: Pheochromocytoma: current status and changing trends. Surgery 91: 367–373, 1982. 7. Mihm FG, Sandhu J, Brown MD, et al: Short-acting beta-adrenergic blockade as initial drug therapy in pheochromocytoma. Crit Care Med 18: 673– 674, 1990.
365vii
LAPAROSCOPIC MANAGEMENT OF BLADDER PHEOCHROMOCYTOMA PAUL M. KOZLOWSKI, FREDRICK MIHM,
AND
HOWARD N. WINFIELD
ABSTRACT Pheochromocytoma primarily involving the bladder is an uncommon pathologic finding. Patients may present with transient hypertension associated with palpitations and diaphoresis on micturition. A case of bladder pheochromocytoma treated by laparoscopic partial cystectomy is presented. The management principles of bladder pheochromocytoma for our specific case are discussed. Successful treatment requires that the correct diagnosis and tumor location be made in conjunction with the obligatory preoperative preparation of the patient. UROLOGY 57: 365v–365vii, 2001. © 2001, Elsevier Science Inc.
A
21-year-old woman presented to her primary care provider with a 2-year history of mildly elevated blood pressure. Her hypertension and an elevated 24-hour urine collection for norepinephrine of 751 g/24 hours (normal 15 to 80) were initially attributed to weight-reducing medications. Hypertension persisted despite discontinuation of these drugs. History revealed that the patient reported episodic palpitations, flushing, light-headedness, and diaphoresis, often occurring with micturition. She denied gross hematuria, urgency, or other lower urinary tract symptoms. Her past medical history was significant for anorexia nervosa and depression. Physical examination was normal. Blood pressure reading on initial presentation demonstrated a systolic range of 108 to 177 mm Hg, diastolic range of 50 to 111 mm Hg, and a pulse rate of 78 to 103 while supine. Preoperative testing included plasma and two 24-hour urine collections for catecholamines; results are shown in Table I. Magnetic resonance imaging (MRI) of the abdomen and pelvis revealed a 3.3 ⫻ 3.1-cm soft tissue mass, extending from the left anterolateral aspect of the bladder. The lesion had a slightly increased T2-weighted image and intermediate T1 signal intensity (Fig. 1). No addiFrom the Departments of Urology and Anesthesia, Stanford University, Stanford, California Address for correspondence: Howard N. Winfield, M.D., Department of Urology, Stanford University School of Medicine, 300 Pasteur Drive, S-287, Stanford, CA 94305-5118 Submitted: June 19, 2000, accepted (with revisions): September 11, 2000 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
tional lesions or evidence to support metastases were found on iodine 131-methyliodobenzylguanidine (131I-MIBG) scintigraphy, chest x-ray, and computed tomography (CT) scan. Prior to surgery the patient received phenoxybenzamine titrated up to 30 mg twice daily and labetalol 150 mg twice daily for 28 days. Blood pressure was brought into the normal range. The patient was evaluated for evidence of cardiac complications of pheochromocytoma. Cardiac enzymes, electrocardiogram, and echocardiography (ejection fraction 55%) were normal. Under general anesthesia, initial cystoscopy demonstrated the lobulated tumor to be a sufficient distance from the ipsilateral ureteral orifice for excision. With the use of a four-port (5 to 10 mm) diamond arrangement, at 15° Trendelenburg, pneumoperitoneum was established. The lesion was dissected from the overlying peritoneum and perivesical fat. Switching to cytoscopy, a Collin’s knife was employed to circumferentially excise around the lesion with a 2-cm margin. The laparoscopic Harmonic Shears (Ethicon Endosurgery) completed the excision. The specimen was removed, using a laparoscopic sac. The cystotomy was repaired, using a single layer of 2-0 polyglactin interrupted sutures, placed laparoscopically, using both the EndoStitch device (Autosuture Corp, Norwalk, Conn) and free-hand intracorporeal suturing. Distension of the bladder at the completion of the repair showed no leakage. A 10F JacksonPratt drain was placed in the pelvis and brought out through a lateral trocar site. A 22F Foley catheter was placed transurethrally into the bladder. 0090-4295/01/$20.00 PII S0090-4295(00)00899-2 365v
TABLE I. Results of plasma and 24-hour urine analysis Normal Values Plasma Norepinephrine (pg/mL) Epinephrine (pg/mL) 24-hour urine Epinephrine (g) Norepinephrine (g) Vanillylmandelic acid (mg) Homovanillic acid (mg) Dopamine (g) Metanephrines (g) Normetanephrines (g)
111–498 ⬍50 (supine) ⬍95 (upright) 0–20 15–80 0–7 0–15 60–440 30–350 50–650
Preoperative 5702 ⬍20
1.0 751 11.1 2.1 146 — —
Postoperative — —
5.0 23 3.6 4.8 274 134 339
Final pathology was consistent with pheochromocytoma of the bladder. Because of the absence of metastases, the tumor is believed to be benign. All surgical margins were free of tumor. COMMENT
FIGURE 1. MRI scan pheochromocytoma.
demonstrating
bladder
RESULTS The patient was normotensive following surgery with occasional episodes of hypotension when sitting or standing too quickly in the first few days. Total surgical time, including transurethral circumferential incision and laparoscopic excision of the tumor with bladder reconstruction, was 300 minutes. Estimated blood loss was less than 200 cc. Clear fluids were resumed within 12 hours of the surgery. Total narcotic requirements were higher than expected during her hospitalization: morphine sulfate intravenously 146 mg, ketorolac tromethamine (Toradol) intramuscularly 120 mg; and oxycodone and acetaminophen (Percocet) 9 tablets. Full ambulation occurred by postoperative day 2. All antihypertensive medication was discontinued during the 4-day hospitalization. Cystogram performed at 2 weeks was normal, at which time her Foley catheter was removed. One month following surgery, she was normotensive and denied any of the symptoms that she experienced preoperatively. Her endocrine panel is normal (Table I). 365vi
Pheochromocytoma of the bladder accounts for less than 0.06% of all bladder tumors.1 Although rare, a high clinical suspicion for pheochromocytoma must be maintained for bladder lesions in hypertensive young patients. Preoperative recognition of such lesions is essential to prevent serious complications. Endocrine and radiographic evaluations aid in the diagnosis of pheochromocytoma. Sixty-five percent of bladder pheochromocytomas present with hypertension.2– 4 Hypertensive crises, potentiated by voiding in 47% to 77% of cases, are characterized by migraines, palpitations, blurred vision, and sweating.5 Elevated catecholamines (epinephrine and norepinephrine) and their metabolites (metanephrine and vanillylmandelic acid) strongly suggest the diagnosis of pheochromocytoma. CT scans are widely used for the localization of pheochromocytomas.6 Additional imaging modalities that are especially useful include MRI and 131 I-MIBG scintigraphy. Careful preoperative alpha blockade (phenoxybenzamine) for at least 1 to 2 weeks is required to counteract the effects of released catecholamines. The use of beta blockers should usually be used after the initiation of alpha blockade if tachycardia or arrhythmias occur.7 CONCLUSIONS We report a single case of pheochromocytoma of the bladder managed by laparoscopic partial cystectomy. After careful preoperative biochemical and radiologic evaluation with detailed surgical UROLOGY 57 (2), 2001
preparation, our patient underwent successful laparoscopic partial cystectomy for this lesion. Application of the combined laparoscopic and endoscopic approaches to partial cystectomy is an attractive alternative to traditional open surgery. However, only a larger series and comparison to open surgical excision of such lesions will determine if this minimally invasive procedure should be considered the preferential approach. REFERENCES 1. Leestma JE, and Price EB: Paraganglioma of the urinary bladder. Cancer 28: 1063–1073, 1971. 2. Das S, Bulusu NV, and Lowe P: Primary vesical pheo-
UROLOGY 57 (2), 2001
chromocytoma of the urinary bladder. Urology 21: 20 –25, 1983. 3. Samaan NA, Hickey RC, and Shutts PE: Diagnosis, localization, and management of pheochromocytoma. Cancer 62: 2451–2460, 1988. 4. Gittes RF, and Mahoney EM: Pheochromocytoma. Urol Clin North Am 4: 239 –252, 1977. 5. Sweester PM, Ohl DA, and Thompson NW: Pheochromocytoma of the urinary bladder. Surgery 109: 677– 681, 1991. 6. van Heerden JA, Sheps SB, Hamberger B, et al: Pheochromocytoma: current status and changing trends. Surgery 91: 367–373, 1982. 7. Mihm FG, Sandhu J, Brown MD, et al: Short-acting beta-adrenergic blockade as initial drug therapy in pheochromocytoma. Crit Care Med 18: 673– 674, 1990.
365vii