PHEOCHROMOCYTOMA CHARLES

M. LINDSEY,

OF URINARY BLADDER

M.D.

H. SYKES DEHART, M.D. JAMES F. GLENN,

M.D.

From the Department of Surgery, Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina

ABSTRACT discussed.

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A patient with pheochromocytoma

Pheochromocytoma is a rare tumor usually occurring in the adrenal medulla. Extra-adrenal lesions are seen in 10 per cent of adults and 31 per cent of children and may arise in any location where paraganglionic tissue is found. ’ There have been some 35 previously reported instances of vesical pheochromocytoma to which this case is added. 1*2

of the urinary bladder is described and management

The patient was initially treated with phenoxybenzamine and bed rest with gradual reduction in the blood pressure. By the fifth hospital day blood pressure was 140/90 mm. Hg. Cystoscopy was performed which demonstrated a S-cm.

Case Report An eighteen-year-old black woman was admitted to the urology service with complaints of headache, flushing, palpitations, and choking sensation precipitated by a full urinary bladder. These symptoms had been intermittently present since age thirteen usually occurring once or twice weekly. She had recently undergone successful pregnancy and parturition complicated by severe hypertension thought to be a manifestation of pre-eclampsia. The patient denied any history of hematuria or antecedent urinary tract infection. Past history, review of systems, and family history were noncontributory. On physical examination the blood pressure was 180/120 mm. Hg supine. There was a faint apical systolic cardiac murmur. Pelvic examination disclosed a firm 5-cm. mass in the anterior bladder wall. Laboratory data included hematocrit 38 and blood urea nitrogen 10 mg. and creatinine 0.9 mg. per 100 ml: Results of urinalysis and urine culture were negative. Twentyfour-hour urine for vanilmandelic acid was 26 mg., epinephrine 351 mg., and norepinephrine 714 mg. Intravenous urogram demonstrated normal upper tracts but an apparent mass lesion within bladder (Fig. 1). Cystogram was normal.

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FIGURE 1. Zntravenous urogram demonstrating filling defect within bladder.

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mass in the anterior portion of the bladder. Phenoxybenzamine was continued in increasing doses until the blood pressure was in the range of 120/80 mm. Hg by the fourteenth hospital day. Blood volume determination indicated a contracted extracellular volume. This was corrected with packed red cell transfusions in the twentyfour hours prior to exploratory surgery. On the sixteenth hospital day exploratory celiotomy was performed. A well-demarcated lesion was removed by partial cystectomy from the anterior bladder wall (Fig. 2A). Histologic examination confirmed the diagnosis of pheochromocytoma (functioning paraganglioma) (Fig. 2B). At the time of surgery the entire abdomen was explored including both adrenal glands. No additional lesions were located. The postoperative course was uncomplicated; blood pressure was normal within seven days. Follow-up twentyfour-hour urinary catecholamines were normal. Comment Diagnosis of pheochromocytoma rests on demonstration of elevated catecholamine levels or their metabolites in the urine. If a high index of suspicion is present, several analyses should be performed since the tumor may secrete only intermittently. 3 Confirmation of location within the bladder may be made by a combination of history, physical findings, and radiologic and endoscopic techniques. Interestingly in this case the tumor was visible on the cystogram phase of the intravenous urogram, but the shadow was obliterated and invisible with standard retrograde cystography. Management of patients with pheochromocytoma requires careful attention to detail and an understanding of the physiologic alterations produced by the high catecholamine levels. Wide fluctuations in blood pressure may occur with any

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stress, especially general anesthesia or surgical of an unsuspected pheomanipulation chromocytoma. Extensive diagnostic and endoscopic studies should be delayed until alphaadrenergic blockade is accomplished with phenoxybenzamine. 4 Extracellular volume is contracted from the chronic sustained effect of the elevated catecholamine levels and should be reexpanded prior to removal of the neoplasm; otherwise profound postoperative hypotension may result. Intraoperative fluctuations in blood pressure may result from tumor manipulation, and for this reason extra care must be exercised during mobilization to preclude a hypertensive crisis.5 We believe that excision of vesical pheochromocytoma should be accompanied by complete abdominal exploration to include examination of both adrenals and the entire retroperitoneum. Follow-up catecholamine determinations are collected in the second postoperative week and should be normal by that time, elevations being indicative of residual tumor.4 Durham, North Carolina 27710 (DR. GLENN) References 1. ALBORES-SAAVEDF~A, J., MALDONADO,M. E., IBARRA, J., and RODRIGUEZ,H. A.: Pheochromocytoma of the urinary bladder, Cancer 23: 1110 (1969). 2. DOCTOR, V. M., PHADKE, A. G., and SIRSAT, M. V.: Pheochromocytoma of the urinary bladder, Br. J. Urol. 44: 351 (1972). Pheo3. BOGAERT, M. G., and VERMEULEN, A.: chromocytoma of the urinary bladder, with inconclusive chemical and pharmacologic tests, Am. J. Med. 53: 797 (1972). 4. OLSON, H. H., PAULSON, P. S., BERLIN, L. B., and OHTAKE, C.: Pheochromocytoma: current concepts of diagnosis and management, Am. Surg. 57: 455 (1971). Urologic Surgery, 2nd ed., Hagerstown, 5. GLENN, J. F.: Harper & Row, 1975, p. 28.

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Pheochromocytoma of urinary bladder.

PHEOCHROMOCYTOMA CHARLES M. LINDSEY, OF URINARY BLADDER M.D. H. SYKES DEHART, M.D. JAMES F. GLENN, M.D. From the Department of Surgery, Division...
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