Pheochromocytomas are rare neuroendocrine tumours with heterogeneous clinical presentations and potential lethal outcomes. Biochemically silent ones with normal catecholamine levels are even rarer.

We present a case of a 69-year-old male who was incidentally found to have a right adrenal gland tumour shown on CT scan done for pneumonia . It was a 3.6 cm tumor in the right adrenal gland suspicious for malignancy. A 4.9 cm contralateral solid tumour in the left kidney was also revealed.

Initially a left nephrectomy with a retroperitoneal open approach was performed . Histopathology showed the presence of a renal cell carcinoma from clear cells. A right adrenalectomy was performed at a second stage with the thought that the tumour in the right adrenal is a metastasis . Initially the procedure was approached laparoscopically. After induction in anaesthesia and during the first surgical manoeuvres the patient developed hypertension 260mmHg . The tumor was attached to the vena cava at the level of the right adrenal vein and conversion to open approach was decided. Sodium nitroprusside , nitrolingual and remifentanil were administered intravenously . Ligation of the main adrenal vein was followed by hypotension treated with intravenous crystalloids . The postoperative course was uneventful. The pathology report showed a pheochromocytoma . The PASS score was 9 (malignant) and Ki67:4%

Medical awareness for pheochromocytomas is necessary for the treatment of any retroperitoneal tumour . Sodium nitroprusside is still the first choice for the treatment of severe intraoperative hypertension crisis