Results and conclusion (351 words):

Shortly after the surgery commenced, the patient abruptly developed a hypertensive crisis, with a peak blood pressure of 210/95 mmHg and requiring the administration of 0.5 mg of nicardipine. The surgery then went ahead. During the manipulation of a 5-cm left pararenal lump, the patient abruptly developed another hypertensive crisis of up to 210/80 mmHg, which was not controlled by the titration of 0.5% bupivacaine in the epidural catheter and which required the titration of nicardipine and an increasing minimum alveolar concentration of sevoflurane. Because of the circumstances, a paraganglioma was suspected. The left nephrectomy was quickly completed, and the patient then experienced severe hypotension, requiring norepinephrine up to 35 µg/min. Mean arterial pressure remained below 60 mmHg, requiring phenylephrine and adrenaline up to 40 µg in conjunction with aggressive filling. Blood pressure normalised after 40 minutes while continuous high doses of norepinephrine were maintained. Due to the haemodynamic instability, the surgeon ordered frozen section biopsies, which confirmed an unsuspected peri-renal paraganglioma. (Figure 3) An intra-aortic-caval lymph node dissection was also performed for tissue samples. The right nephrectomy proceeded uneventfully. Blood loss was estimated at 700 ml. The abdomen was closed, and the patient was transferred to the intensive care unit, sedated and intubated. No organ failure occurred during the patient’s intensive care unit stay. On day 1, she was weaned off aminergic support and successfully extubated. On day 7, she presented with an occlusion of the arteriovenous fistula. Surgical unblocking was performed under local anaesthesia and sedation with propofol, with no complications. No other postoperative complications were noted. The patient spent a further 22 uneventful days in the Department of Visceral Surgery. She was discharged home from the hospital and returned for dialysis three times a week. Unexpectedly, the definitive pathology report revealed a 13-cm metastasis of the previously diagnosed myxoid liposarcoma on the right side. The lymph node dissection showed 7 negative nodes and a second 0.4-cm paraganglioma. On day 25, the patient went home with follow-up appointments at the Nephrology and Oncology outpatient clinics. Due to the patient’s metastatic state, the whole transplantation project was put under review.