Background and Objectives Pheochromocytomas are rare catecholamine-secreting tumors that arise from chromaffin tissue within the adrenal medulla and extra adrenal sites (paraganglioma). Due to excess secretion of catecholamines, these tumors often cause debilitating symptoms ending in death if actions are not taken. Management requires competent physicians, surgeons and anesthesiologists. The main objective the study focused on pattern of presentation and treatment challenges of pheochromocytoma patients over a period of 21 years (1992- 2012) Methodology A retrospective study of patients undergoing adrenelectomy at KCMC Urology Institute during the course of 20 years and histologically confirmed cases of pheochromocytoma were enrolled. A structured data collection sheet was designed with parameters of demographic data, disease presentation, investigations done, tumor localization, surgical technique and follow up, in a course of overseeing the challenges in each step of management. Results A total of 13 patients were included in the study, 7 were female, median age of participants was 25 years. All patients presented with headache, palpitation and sweating. Neither biochemical nor clonidine suppression test were done. Localization of the tumor was done with ultrasonography, Computer Tomography scan and on surgical exploration. All cases were found to have unilateral tumor and 11 were on the right side and 2 on the left side. Malignancy was confirmed in 1 case. Chevron incision was the main surgical approach. Twelve patients got cured at the first 3 month visit and one died in the ward. Conclusion With respect of the number of patients seen in 21 years Pheochromocytoma is a rare condition. Surgery is the mainstay treatment of the condition. There is a challenge in biochemical and radiological investigation of Pheochromocytoma in our setup, though Ultrasound and CT scan was able to localize Pheochromocytoma in all cases studied. Another challenge was patients had to purchase Phenoxybenzamine and Phentolamine which are not locally available. Recommendations An Author recommend, though the condition seems to be rare patients having Pheochromocytoma should not left unattended as the disease is curable. There is a necessity of having biochemical reagent in our centre. Pre- and intra-operative blood pressure stabilizing medication should be made readily available in our center. In future attention should be paid to follow up using mobile phones to text blood pressure and pulses taken in nearby dispensaries and hospitals to reveal any sign of recurrence. There is a need to conduct a prospective study and look on adrenal autopsy in all cases suspected having pheochromocytoma.