Adrenalectomy

Laparoscopic adrenalectomy is being performed with increasing frequency in nonpreg-nant patients and is considered by some as the preferred approach (93).

Laparoscopic adrenalectomy for pheochromocytoma has been demonstrated to provide as much hemodynamic stability as open adrenalectomy during tumor manipulation with the added benefits of laparoscopic procedures (94). Nine cases of laparoscopic adrenalectomy during pregnancy have been reported in the literature for primary hyperaldosteronism, Cushing's syndrome, and pheochromocytoma (95-101). The retroperitoneal approach was used in one patient (97), whereas a transperitoneal approach was performed in the other eight.

Pheochromocytomas are responsible for 0.05% to 0.1% of all causes of hypertension and are rare during pregnancy with less than 200 cases reported in the literature (102,103). Although the most common symptoms in nonpregnant patients are hypertension, headaches, sweating, and palpitations, hypertension and headaches seem to predominate during pregnancy. While these tumors are rarely the cause of hypertension during pregnancy, if unrecognized or untreated they pose serious risks to both the mother and fetus. Maternal mortality rates have been reported in 17% to 48% and fetal demise in 26% to 54% of untreated cases (104-106). With early detection and treatment these mortality rates may be dramatically improved, with reported lows of 0% to 15% (105-107). Unfortunately, antenatal diagnosis is made in only 53% of cases (106).

Pheochromocytoma should be considered in the differential diagnosis of any pregnant patient developing hypertension prior to the 20th week of gestation. The diagnosis of pheochromocytoma can be made by measuring urinary chatecholamines as with nonpregnant patients because these levels are unaffected by the pregnant state. Pre-eclampsia is high on the differential of hypertension during pregnancy but may be distinguished from pheochromocytoma by the presence of proteinuria, oliguria, and thrombocytopenia in the third trimester (108). Ultrasound and magnetic resonance imaging are the preferred localization studies.

Laparoscopic splenectomy has been shown to be advantageous when compared to open splenectomy and is comparable to open splenectomy in terms of safety and efficacy in nonpregnant patients.

Successful treatment of pheochromocytomas requires a multidisciplinary approach including the obstetrician, endocrinologist, anesthesiologist, and surgeon. Once the diagnosis is established, pharmacologic therapy should be started immediately. Alpha-adrenergic blockade with phenoxybenzamine is used to control hypertension and, if necessary, selective beta-blockade with metoprolol or atenolol is used to control tachycardia during pregnancy (103). Control of hypertension is vital in these patients because severe hypertension can result in uteroplacental insufficiency, early separation of the placenta, and fetal death. Phenoxybenzamine decreases the systemic peripheral vascular resistance and will allow for intravascular volume replacement before surgery. If diagnosed in the third trimester, removal of the tumor is delayed until after delivery if blood pressure can be controlled medically (100,109). To date, there have been four case reports of laparoscopic adrenalectomy for pheochromocytoma in the pregnant patient which were performed between 13 and 20 weeks gestation (99-101). General guidelines for laparoscopy during pregnancy were followed including dependent positioning without significant alterations in the standard technique used for nonpregnant patients. In each case, the mother delivered a healthy infant.

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