Predicting Hemodynamic Fluctuations During Adrenalectomy for Pheochromocytoma

<b>Background:</b> Pheochromocytoma is a rare adrenal neuroendocrine tumor characterized by excessive catecholamine secretion, which can lead to significant perioperative hemodynamic instability. Despite advances in anesthetic and surgical management, intraoperative hypotension is a common complication. This study aimed to identify preoperative and intraoperative predictors of hemodynamic instability during adrenalectomy for pheochromocytoma in order to improve intraoperative management and patient safety. <b>Methods:</b> This retrospective study included adult patients who underwent adrenalectomy for pheochromocytoma at the University Clinical Center of Serbia between January 2022 and June 2025. Preoperative clinical and biochemical data, tumor characteristics evaluated by imaging methods (CT or MRI), surgical approach, and intraoperative hemodynamic parameters were analyzed. Intraoperative hypotension was defined as mean arterial pressure (MAP) < 60 mmHg despite adequate volume resuscitation. Univariate and multivariate logistic regression analyses were performed to identify predictors of hypotension. <b>Results:</b> A total of 51 adult patients were included in the analysis. Intraoperative hypotension occurred in 26 patients (51%) and was significantly associated with larger tumor size and increased intraoperative fluid requirements. Multivariate analysis identified tumor diameter ≥ 49 mm (OR 0.176, 95% CI 0.034-0.895, <i>p</i> = 0.036) and intraoperative crystalloid infusion ≥ 1200 mL/h (OR 0.132, 95% CI 0.030-0.574, <i>p</i> = 0.007) as independent predictors of intraoperative hypotension. Preoperative catecholamine levels, surgical approach, and type of alpha-blocker were not significant predictors. <b>Conclusions:</b> Tumor size was identified as a significant predictor of intraoperative hemodynamic instability during adrenalectomy for pheochromocytoma. Careful preoperative assessment and individualized intraoperative fluid management may help reduce the risk of hypotension and optimize perioperative outcomes.