Introduction

Retroperitoneal paragangliomas are rare neuroendocrine tumors that arise from chromaffin cells located outside the adrenal glands. These tumors can secrete catecholamines, leading to significant cardiovascular and systemic symptoms. Surgical removal remains the definitive treatment, but the procedure can be technically challenging due to the tumor’s proximity to major blood vessels and vital organs.

This case study describes the successful robotic excision of a functional retroperitoneal paraganglioma in a young patient, managed by Dr. Mohamad Ali, a urologic oncologist and robotic surgeon practicing at Apollo Hospitals, Pune. The case highlights the importance of careful preoperative preparation, precise surgical technique, and close multidisciplinary coordination.

Surgeon’s Clinical Background

Dr. Mohamad Ali is a fellowship-trained Urologic Oncologist and Robotic Surgeon with over 10 years of surgical experience. His clinical focus includes uro-oncology and advanced robotic procedures for urological cancers. He has completed an advanced post-doctoral clinical fellowship in Uro-Oncology and Robotic Surgery with the Vattikuti Foundation (USA & India) at Medanta Hospital and has undergone observing fellowships at St. Guy’s and St. Thomas’ Hospital, London (UK) and ORSI Academy, Belgium. His training emphasizes minimally invasive approaches for complex oncological cases.

Patient Profile

• Age: 19 years
• Gender: Female
• Referral: General Practitioner

The patient was referred for further evaluation due to persistent systemic symptoms and newly diagnosed hypertension.

Presenting Complaints

The patient reported the following symptoms for approximately six months:

• Recurrent headaches
• Palpitations
• Excessive sweating
• Right-sided flank pain
• Irregular menstrual cycles

These symptoms were episodic and progressively affecting her daily activities.

Clinical Examination

On physical examination, the patient was found to be hypertensive, raising suspicion of a secondary cause of hypertension, particularly given her age and associated symptoms. No palpable abdominal mass was detected.

Biochemical Evaluation

To assess for a catecholamine-secreting tumor, biochemical tests were performed.

• Plasma free normetanephrines: ~2900 ng/mL
• Reference range: ≤180 ng/mL

The markedly elevated levels confirmed the presence of a functional neuroendocrine tumor, consistent with a paraganglioma.

Preoperative Medical Optimization

Given the functional nature of the tumor and the risk of severe blood pressure fluctuations during surgery, a structured preoperative plan was implemented.

• The endocrinology team initiated alpha-adrenergic blockade, followed by beta-blockade, to achieve optimal blood pressure and heart rate control.
• Adequate hydration and monitoring were ensured to reduce perioperative cardiovascular risks.

This preparation was essential to minimize complications during tumor manipulation.

Imaging Findings

Contrast-enhanced imaging of the abdomen revealed:

• A 3 × 3 cm retroperitoneal mass located above the inferior vena cava (IVC) and abdominal aorta
• Close relation to the inferior wall of the fourth part of the duodenum, with focally indistinct fat planes
• Indentation of the adjacent IVC and extension into the interaortocaval region, with likely preserved fat planes between the tumor and major vessels
• Close proximity to a small right accessory renal artery, with maintained intervening fat planes

These findings confirmed the complex anatomical location of the tumor and the potential surgical challenges.

Surgical Planning and Approach

After multidisciplinary discussion involving urology, endocrinology, anesthesia, and radiology teams, a robotic surgical approach was planned.

The rationale for robotic surgery included:

• Enhanced three-dimensional visualization
• Improved precision in confined retroperitoneal spaces
• Better control while working near major blood vessels
• Reduced tissue trauma compared to open surgery

Surgical Procedure

The patient underwent robotic excision of the retroperitoneal paraganglioma using a minimally invasive robotic system.

Key intraoperative considerations included:

• Careful dissection due to proximity to the aorta, IVC, duodenum, and accessory renal artery
• Anticipation of intraoperative blood pressure fluctuations, managed continuously by the anesthesia team
• Stepwise and controlled tumor mobilization to prevent catecholamine surges

Despite the technical complexity, the tumor was completely excised without injury to adjacent vascular or bowel structures.

Postoperative Outcome

• Extent of resection: Complete tumor excision
• Complications: None
• Blood pressure: Normalized postoperatively
• Hospital stay: Discharged in stable condition on postoperative day 1

The patient recovered well and required no additional antihypertensive medication at discharge.

Discussion

This case demonstrates that robotic surgery can be a safe and effective option for managing selected retroperitoneal paragangliomas, even in anatomically challenging locations. Functional tumors require meticulous preoperative optimization and vigilant intraoperative monitoring to reduce cardiovascular risks.

The success of this case was dependent on:

• Accurate biochemical and radiological diagnosis
• Structured preoperative endocrine management
• Robotic precision allowing careful dissection near vital structures
• Close collaboration between surgical, anesthesia, and medical teams

Conclusion

Robotic excision of a functional retroperitoneal paraganglioma is feasible and can lead to favorable outcomes when performed with appropriate planning and multidisciplinary support. This case highlights the role of minimally invasive robotic techniques in managing complex neuroendocrine tumors while prioritizing patient safety and recovery.