Advancements and Challenges in the Preoperative Management of Pheochromocytoma in a Low- and Middle-Income Country (LMIC): A Nationwide Survey.

BACKGROUND

Pheochromocytomas are rare catecholamine-producing neoplasms of the adrenal medulla that present considerable perioperative management challenges. Despite advances in pharmacologic protocols and surgical techniques, clinical variability, particularly in drug availability (e.g., phenoxybenzamine vs. doxazosin), lack of standardized titration protocols, and inconsistent multidisciplinary planning continue to affect management.

OBJECTIVE

This study examines contemporary trends in the preoperative management of pheochromocytoma through a national survey of surgical professionals in Pakistan, aiming to uncover prevailing practices, highlight systemic gaps, and inform evidence-based refinements to current protocols.

METHODS

A structured survey was disseminated to 196 practicing healthcare professionals across academic and non-academic institutions over a period of four months. Eligible participants were MBBS-qualified surgical professionals with at least one year of training and experience in the preoperative or operative management of adrenal tumors. Data were analyzed using descriptive statistics for quantitative trends and thematic analysis for qualitative feedback.

RESULTS

Among respondents, 137/196 (69.9%) had experienced managing 1-20 pheochromocytoma cases, while 30/196 (15.3%) had operated on more than 20 cases. Blood pressure charting was one preferred preoperative evaluation method (127/196 (64.8%)), followed by confirmation through biochemical testing and localization through imaging. Selective alpha-blocker use (78/196, 39.8%) reflects both clinical preference and limited access to non-selective agents. Beta-blockers were used adjunctively by 137/196 (69.9%) to manage reflex tachycardia. Combination therapy of alpha- and beta-blockers was the predominant regimen (118/196 (60.2%)). For normotensive or alpha-blocker-intolerant patients, calcium channel blockers alone or with beta-blockers were preferred (127/196 (64.8%)). Common side effects included orthostatic hypotension (117/196 (59.7%)) and reflex tachycardia (87/196 (44.4%)). Multidisciplinary approaches involving endocrinologists and cardiologists were endorsed by 147/196 (75%). Challenges such as uncontrollable hypertension (69/196 (35.2%)) and patient non-compliance (59/196 (30.1%)) were frequently reported, with hospital admission (98/196 (50%)) and multidisciplinary collaboration (118/196 (60.2%)) used as mitigation strategies. Recent advancements such as the adoption of selective alpha-blockers, combination therapies, and invasive perioperative monitoring were associated with improved blood pressure control, reduced intraoperative instability, and enhanced overall management efficiency. The data revealed a shifting preference toward selective alpha-blockers and increased use of combination therapies. However, inconsistencies in drug titration, underutilization of structured protocols, and limited access to minimally invasive surgery remain problematic. Key qualitative themes included pharmacologic evolution, patient non-compliance, intraoperative instability, and calls for formalized training pathways.

CONCLUSION

The evolving landscape of pheochromocytoma management demands a more cohesive integration of pharmacological precision, multidisciplinary planning, and institutional standardization. Bridging gaps in training and access, while refining clinical protocols, will be essential to advancing safe and effective surgical outcomes.