Preparation for surgical removal of a pheochromocytoma includes:

B. Hydration.

C. Alpha-adrenergic blockade, with or without beta-adrenergic blockade.

E. Planning removal through an anterior, posterior, or laparoscopic approach based upon tumor localization with CT, magnetic resonance imaging (MRI), and/or 131I-MIBG.

DISCUSSION: Principles of preoperative management for pheochromocytoma include preoperative alpha-adrenergic blockade using phenoxybenzamine or phentolamine. Beta-adrenergic blockade with propranolol is then used selectively in patients who develop tachycardia, have a history of cardiac arrhythmia, or have primarily epinephrine-secreting tumors. Beta-adrenergic blockade should be undertaken only after successful alpha blockade is established. Patients with pheochromocytoma frequently exhibit intravascular volume depletion, and careful hydration is mandatory. Central venous pressure monitoring alone is helpful to guide hydration; more intensive monitoring with a Swan-Ganz catheter is indicated for patients with pre-existing heart disease. Formerly, the anterior approach was preferred for adrenalectomy as it facilitated complete abdominal exploration and search for extra-adrenal pheochromocytoma. Accurate preoperative localization with CT, MRI, and 131I-MIBG has allowed selective use of the posterior, or even the laparoscopic, approach for adrenalectomy