Precarious encounter with Paraganglioma during cystoscopic excisional biopsy of urinary bladder tumour

Tumours secreting catecholamine are a known perioperative anaesthetic challenge. However, extra adrenal location of such tumors can cause sudden catastrophe in unprepared patients.

A 45 year old, 50 kg female patient scheduled for transurethral cystoscopic resection of bladder tumour of suspected neoplastic aetiology, developed sudden, severe tachycardia, hypertension, and arrhythmias followed by hypotension under general anaesthesia. Tumour biopsy obtained during first surgery confirmed diagnosis of Paraganglioma (PGL). This was supported with normal vanillyl mandelic acid (VMA), 6.5mg/24hrs (normal 2-8mg/24hrs) and a large polypoidal mass on CT in a patient with episodic symptoms of headache and blackout associated with micturition; a classical triad reported about this tumour category. Findings of MIBG (Meta iodo benzyl guanidine) ¹³¹I scan that reported no MIBG avid disease, were equivocal.

Accurate diagnosis, good perioperative control of blood pressure and volume status using invasive monitoring and cascade of drugs to manipulate circulation when required, formed the essence of successful management of the patient during her second surgery.