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Perception Versus Reality - A Case-matched Study Assessing The Intraoperative Hemodynamics Of Retroperitoneal Versus Transperitoneal Endoscopic Approach To Pheochromocytomas
*Caitlin T Yeo, *Danae Krahn, *Adrian Harvey, Janice L Pasieka
University of Calgary, Calgary, AB, Canada

OBJECTIVE(S): Pheochromocytomas produce excess catecholamines that can result in hemodynamic fluctuation during surgery. Multiple centers have reported increased hemodynamic instability with the endoscopic retroperitoneal (RP) approach compared to the laparoscopic transperitoneal (LA) approach, hypothesizing the delayed ligation of the adrenal vein and blunt dissection on the tumor in the RP approach leads to increased systemic catecholamine release. However, once the RP approach was initiated for pheochromcytomas at our institution, the local perception was the opposite, that there was improved intraoperative hemodynamics. We hypothesized that the increased RP insufflation pressures resulted in decreased venous return leading to less fluctuation in circulating catecholamines. The purpose of this study was to examine if a difference in intraoperative stability exists between a matched cohort of RP and LA pheochromocytoma patients.
METHODS: Patients undergoing unilateral adrenalectomy for pheochromocytoma performed via RP or LA from 2015-2021 were identified from a prospective surgical database. To eliminate bias, as larger tumors are often selected for LA, cases were matched 1:1 by tumor size. All patients received α-blockade as per our institutionís multidisciplinary protocol. The two groups were compared with respect to: 1) patient and tumor characteristics; 2) pre-operative blockade; 3) intra-operative hemodynamics and management; and 4) early post-operative outcomes. Comparisons were made using paired t-test.
RESULTS: There were 13 RP pheochromcytoma cases identified and matched to 13 LA cases according to tumor size (2.2 vs. 2.9cm, p=0.06). Both groups (RP vs. LA) were similar for age (53 vs. 53years, p=0.98), BMI (29.7 vs. 28.5, p=0.63), gender (both 69% female) and side (7 vs. 8 right). There was no difference in pre-operative 24-hour urine metanephrines/normetanephrines (2.4/5.7 vs. 9.9/8.0umol/day, p=0.24/0.64). The preoperative phenoxybenzamine dose was similar in both groups (114 vs. 112mg/24hr, p=0.96), as were baseline HR, BP, and MAP. Intraoperatively, there was no difference in any hemodynamic parameters or number of vasoactive interventions between groups. Operative time, length of stay, and 30-day emergency visits were similar between groups.
CONCLUSIONS: Despite our own perception, this matched cohort study revealed that there is no difference in intraoperative hemodynamics between RP and LA approaches for pheochromocytoma in appropriately selected and α-blocked patients.


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