A 45-year-old man with a 5 cm right adrenal mass is scheduled for adrenalectomy. 24-hour urine metanephrines are elevated. Which preoperative management is essential before surgery?
- A Immediate surgical resection without delay
- B Alpha-adrenergic blockade (phenoxybenzamine) first, then beta-blocker if needed ✓
- C Beta-blocker alone started on the day of surgery
- D High-dose glucocorticoid replacement only
Correct answer: B. Alpha-adrenergic blockade (phenoxybenzamine) first, then beta-blocker if needed
Explanation
Pheochromocytoma surgery risks massive catecholamine release causing hypertensive crisis. Alpha-blockade with phenoxybenzamine is started first (7 to 14 days preoperatively) to control blood pressure and expand volume. Beta-blockers are added only AFTER adequate alpha-blockade to avoid unopposed alpha-mediated vasoconstriction. Giving beta-blocker first or skipping blockade risks intraoperative hypertensive emergency.
Reference: Williams Textbook of Endocrinology, 14th ed.
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