Robot-assisted laparoscopic partial adrenalectomy for pheochromocytoma: the National Cancer Institute technique.

BACKGROUND: Partial adrenalectomy has recently been advocated to preserve unaffected adrenal tissue during resection of pheochromocytoma. OBJECTIVE: To describe a robot-assisted laparoscopic partial adrenalectomy (RALPA) technique and to report on early functional and oncologic outcomes. DESIGN, SETTING, AND PARTICIPANTS: From 2007 to 2010, 15 RALPA were performed on 12 consecutive patients with pheochromocytoma. Follow-up data of >1 yr are available on 11 procedures. Median follow-up for the entire cohort was 17.3 mo (range: 6-45). SURGICAL PROCEDURE: Positioning and port placement is designed for adequate reach and visualization of the upper retroperitoneum. The plane between the adrenal cortex and pheochromocytoma pseudocapsule is identified visually and with laparoscopic ultrasound. The tumor is dissected away from normal adrenal cortex, preserving normal adrenal tissue. MEASUREMENTS: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS AND LIMITATIONS: Fourteen of 15 cases were completed robotically. Among 15 procedures, 4 were performed on a solitary adrenal gland. Four cases required resection of multiple tumors (up to six) with two performed in a solitary gland. The mean age of the patients was 30 yr, and the mean body mass index was 27. The mean operative time was 163 min, the median estimated blood loss was 161 ml, and the median tumor size was 2.7 cm (range: 1.3-5.5). There was one conversion to an open procedure in a patient requiring reoperation on a solitary adrenal gland. One patient who underwent RALPA on a solitary adrenal gland required postoperative steroid supplementation at last follow-up. At a median follow-up of 17.3 mo (range: 6-45), there were no recurrences or metastatic events. Study limitations include small sample size and short follow-up. CONCLUSIONS: RALPA for the treatment of pheochromocytoma is feasible and safe and provides encouraging functional and oncologic outcomes, even in patients with a solitary adrenal lesion or multiple ipsilateral lesions.

Financial and educational costs of the residency interview process for urology applicants.

OBJECTIVES: To investigate the financial and educational costs of the urology residency interview process, we performed a survey of the applicants to the 2006 urology match. METHODS: All applicants registered for the 2006 urology match were invited to participate. In January 2006 prior to the match, an anonymous online survey containing 8 questions on the financial and educational costs of the interview process was distributed via email. RESULTS: Survey response rate was 61% (287/468). The median educational debt of the applicants was $125,000 (IQR 65,000 to 160,000). Respondents reported having a median 12 interviews (IQR 8 to 15) with urology residencies and spending a median 20 days (IQR 14 to 30) on the interview trail. The total cost of the interview process was a median $4000 (IQR 2000 to 5200) with a median expense per interview of $330 (IQR 211 to 455). Applicants reported that travel expenses accounted for a median 60% of overall interview expenses, whereas the remainder of the expense was accounted for by lodging (25%), food (10%) and clothing (5%). The money to cover these interview-related expenses was obtained primarily by loans. Forty-six percent of the applicants reported that skipping medical school clerkships and classes for urology interviews was "not at all detrimental" to their medical education, whereas 1% reported that it was "greatly detrimental." CONCLUSIONS: The financial cost of the interview process for urology applicants is substantial, although the educational cost appears to be limited. Efforts to reduce the financial impact of the interview process should be initiated at both a regional and national level.

Local control and long-term disease-free survival for stage D1 (T2-T4N1-N2M0) prostate cancer after radical prostatectomy in the PSA era.

OBJECTIVES: With the advent of prostate-specific antigen (PSA) screening, the number of lymph node metastases found after radical prostatectomy (RP) has been decreasing. Although it has been shown in this population that immediate adjuvant androgen deprivation therapy (ADT) improves survival compared with initiating ADT at clinical recurrence, the effect of starting ADT at biochemical recurrence is unknown. We examined a series of patients with Stage D1 (T2-T4N1-N2M0) prostate cancer discovered after RP, most of whom started ADT at biochemical recurrence. METHODS: A total of 2121 patients underwent RP and bilateral pelvic lymph node dissection from January 1990 and December 2000. Of these men, 28 had lymph node metastases (1.3%), 24 of whom had adequate follow-up data for analysis. RESULTS: No perioperative or long-term complications, such as pelvic recurrence, gross hematuria, urinary retention, or hydronephrosis, developed. With a median follow-up of 74 months, the estimated 5-year survival rate was 94%, similar to the average life expectancy of age-matched men in the United States. The 5-year biochemical disease-free survival rate was 15%. A total of 18 patients who did not start immediate ADT had an estimated 100% overall survival rate at 5 years. CONCLUSIONS: The results of our study have shown that survival for patients with Stage D1 prostate cancer after RP is excellent and equivalent to that of age-matched controls. Long-term pelvic morbidity due to primary tumor progression was prevented by RP. By waiting until PSA failure to initiate ADT, we found that a small percentage of patients (15% at 5 years) were rendered disease free with surgery alone and could avoid the side effects of ADT, with excellent overall survival maintained for those starting ADT at biochemical progression.