Anaesthetic Management of a Functional Urinary Bladder Paraganglioma Presenting with Recurrent Intraoperative Hypertensive Crises: A Case Report

Urinary bladder paragangliomas are rare neuroendocrine tumours presenting significant diagnostic and anaesthetic challenges due to unpredictable catecholamine release and potential haemodynamic instability. We report a 29-year-old male with recurrent haematuria, headaches, and palpitations who experienced two aborted transurethral resection procedures due to intraoperative hypertensive crises (260/140 mmHg and 220/130 mmHg). Biochemical evaluation revealed elevated 24-hour urinary normetanephrine levels (396.26 µg/24 h), and MRI confirmed a 35×39×27 mm lesion on the left posterolateral bladder wall. Following preoperative optimisation with oral prazosin and metoprolol, partial cystectomy was performed under combined general and epidural anaesthesia with invasive monitoring. Intraoperatively, the classic biphasic haemodynamic pattern was observed: hypertension (164/92 mmHg) during tumour manipulation, managed with nitroglycerin and esmolol, followed by precipitous hypotension (70/40 mmHg) after devascularisation, requiring noradrenaline infusion. An additional hypertensive episode during position change was successfully controlled. The patient was successfully extubated without complications and subsequently transferred to the Post-Anaesthesia Care Unit (PACU) in a stable condition. This case emphasises the need to consider bladder paraganglioma as a potential cause of unexplained intraoperative hypertensive episodes. It also demonstrates that optimal outcomes depend on adequate preoperative alpha-adrenergic blockade, careful invasive hemodynamic monitoring, prompt availability of vasoactive medications, and effective coordination within a multidisciplinary team.