Intraoperative hypotension caused by oral administration of 5‐aminolevulinic acid for photodynamic diagnosis in patients with bladder cancer

Abstract

Objective To analyze perioperative blood pressure in patients undergoing transurethral resection of bladder tumor with photodynamic diagnosis. Methods A total of 109 consecutive patients who underwent photodynamic diagnosis‐assisted transurethral resection of bladder tumor at Kanazawa University, Kanazawa, Ishikawa, Japan, were included in this study and considered as the photodynamic diagnosis group. Clinical data were collected, and perioperative systolic bladder pressure and vasopressor usage were analyzed. In contrast, consecutive patients who previously underwent conventional transurethral resection of bladder tumor (without the use of oral 5‐aminolevulinic acid) were used as the control group. Results The systolic blood pressure before anesthesia, lowest systolic blood pressure from the anesthesia induction to the start of operation and lowest systolic blood pressure during operation were significantly lower in the photodynamic diagnosis group. The rate of vasopressor use was significantly higher in the photodynamic diagnosis group. On multivariate analysis, we found that general anesthesia and regular use of renin–angiotensin system inhibitor were associated with an increased risk of hypotension (lowest systolic blood pressure from the anesthesia induction to the start of operation <80 mmHg). Conclusions Oral intake of 5‐aminolevulinic acid can obviously cause a drop in intraoperative blood pressure in patients undergoing transurethral resection of bladder tumor. Therefore, urologists and anesthesiologists should consider withdrawal of renin–angiotensin system inhibitors and monitor the blood pressure during photodynamic diagnosis‐assisted transurethral resection of bladder tumor.

Hypotension caused by oral administration of 5-aminolevulinic acid persists after surgery in patients undergoing transurethral resection of bladder tumor under spinal anesthesia

“…To the Editor, 5-Aminolevulinic acid (ALA) is utilized for photodynamic diagnosis to detect superficial bladder cancer and its adverse effect is hypotension [1][2][3][4][5]. Compared to general anesthesia, spinal anesthesia is not indicated as an increased risk factor for 5-ALA-induced hypotension from anesthesia induction to the start of surgery in patients undergoing transurethral resection of bladder tumor (TUR-BT) with 5-ALA [2,3]. However, no studies exist that have investigated the precise perioperative hypotensive effects by 5-ALA under spinal anesthesia.…”

Preanesthetic severe postural hypotension following 5-aminolevulinic acid pretreatment in patients for photodynamic diagnosis-assisted urological surgery

“…5-ALA may induce vasodilative action [5]; however, it is debatable whether severe hypotension is ascribed only to vasodilative action because 5-ALA does not always induce severe BP decrease and its dose-response relationship is unclear. According to previous researches, there have been some concerns about the relationship between 5-ALA-induced hypotension and antihypertensive therapy [6,7]. Although preanesthetic antihypertensive may be a factor spurring hypotension, it is uncertain whether the severe postural hypotension was only due to 5-ALA pretreatment in combination with the antihypertensive because 5-ALA-pretreated patients medicated together with antihypertensive have not always experienced preanesthetic severe hypotension in clinical practice.…”

Editorial Comment from Dr Fukuhara to Intraoperative hypotension caused by oral administration of 5‐aminolevulinic acid for photodynamic diagnosis in patients with bladder cancer

“…Nohara et al. reported the induction of intraoperative hypotension by 5‐aminolevulinic acid . The incidence of intraoperative hypotension is a rare, but important, problem.…”