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Laparoscopic surgery and robotic surgery, two forms of minimally invasive surgery (MIS), have recently experienced a large increase in utilization. Prior studies have shown that video game experience (VGE) may be associated with improved laparoscopic surgery skills; however, similar data supporting a link between VGE and proficiency on a robotic skills simulator (RSS) are lacking. The objective of our study is to determine whether volume or timing of VGE had any impact on RSS performance. Pre-clinical medical students completed a comprehensive questionnaire detailing previous VGE across several time periods. Seventy-five subjects were ultimately evaluated in 11 training exercises on the daVinci Si Skills Simulator. RSS skill was measured by overall score, time to completion, economy of motion, average instrument collision, and improvement in Ring Walk 3 score. Using the nonparametric tests and linear regression, these metrics were analyzed for systematic differences between non-users, light, and heavy video game users based on their volume of use in each of the following four time periods: past 3 months, past year, past 3 years, and high school. Univariate analyses revealed significant differences between heavy and non-users in all five performance metrics. These trends disappeared as the period of VGE went further back. Our study showed a positive association between video game experience and robotic skills simulator performance that is stronger for more recent periods of video game use. The findings may have important implications for the evolution of robotic surgery training.

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Oncocytic tumors, composed of eosinophilic, mitochondria-rich cells, can occur in several locations throughout the body. These tumors can occur in the adrenal cortex and are rarely malignant. We report a case of a patient presenting with an incidental adrenal mass which was later diagnosed as a oncocytic adrenocortical neoplasm (OAN). The patient is a 53-year-old man found to have a 7.2 cm right adrenal mass, incidentally found by computed tomography (CT). After metabolic workup was negative, a right robotic adrenalectomy (RA) was performed. Pathologic analysis revealed clusters of large cells with abundant eosinophilic and granular cytoplasm, consistent with OAN. This pathology is rare, with only about 150 cases described in the literature. It occurs in females 2.5 times more frequently and more commonly on the left side. Diagnosis is usually made by imaging criteria, typically with CT or magnetic resonance imaging (MRI). Treatment is generally surgical, since OAN can be malignant in some cases. Differentiation between benign and malignant OAN is done based on the Lin-Weiss-Bisceglia criteria and can be difficult. If malignancy is diagnosed, recurrence is common and close surveillance should be performed.

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INTRODUCTION: The role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer (PCa) is controversial. Despite extensive research in both patterns of lymphatic drainage and the clinical effect of lymph node involvement, the exact role of PLND in PCa is yet to be defined. METHODS: A systematic search of the MEDLINE database was performed, and all relevant articles were reviewed in depth. RESULTS: We included 84 relevant articles in our review and subdivided the information into the following categories: preoperative patient evaluation, procedure/extent of dissection, complications, and robotic surgery era. Most authors agree that the greatest benefit is seen in patients with high-risk PCa undergoing RP. Multiple imaging modalities have been evaluated for assistance in patient selection, but the use of preoperative nomograms appears to be the most helpful selection tool. The role of limited PLND vs. extended PLND (e-PLND) is yet to be defined, though many authors agree that e-PLND is preferred in the setting of high-risk PCa. Although PLND is associated with a higher incidence of complications, especially lymphocele formation, it is unclear whether e-PLND leads to more complications than limited PLND. The introduction of minimally invasive surgery may have had a negative effect on implementation of PLND in the appropriate patients undergoing RP. CONCLUSION: Despite a lack of prospective, randomized trials evaluating PLND in RP, there does appear to be a consistent benefit in patients with high-risk disease.

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Collecting duct carcinoma (CDC) is a rare and aggressive form of renal cell carcinoma (RCC) arising from the principal cells of the collecting duct. One third of cases present with metastatic disease, but many present in a manner similar to conventional RCC or urothelial carcinoma (UC). We discuss a case of CDC which presented as a small mass at the cortico-medullary junction, and was discovered at robotic partial nephrectomy (RPN) to be grossly involving the collecting system. A 62-year-old man presented with a small renal mass suspicious for RCC, which was found on computed tomography (CT) after an episode of gross hematuria. After thorough workup, RPN was attempted; however, intraoperatively the mass was found to be involving the collecting system. Radical nephroureterectomy was performed, and the pathology report revealed CDC. CDC is a rare and aggressive form of RCC. While many cases are metastatic at diagnosis, most patients present with the incidental finding of a small renal mass. There are no reports of a CDC involving the collecting system at RPN after negative ureteroscopy preoperatively. The adjuvant therapeutic options for CDC are limited, and long term survival is poor.

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PURPOSE: With the increasing incidence of small renal masses, there is greater use of ablation, nephron sparing surgery and surveillance compared to radical nephrectomy. However, patterns of care in the use of posttreatment imaging remain uncharacterized. The purpose of this study is to determine the rate of posttreatment imaging after various treatments for small renal mass. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results)-Medicare data during 2005 to 2009, we identified 1,682 subjects diagnosed with small renal mass and treated with open partial nephrectomy (330), minimally invasive partial nephrectomy (160), open radical nephrectomy (404), minimally invasive radical nephrectomy (535), thermal ablation (212) and surveillance (42). Use of imaging was compared within 24 months of treatment and multivariate regression models were constructed to identify factors associated with increased imaging use. RESULTS: On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy (OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent. CONCLUSIONS: Subjects undergoing nephron sparing surgery undergo more posttreatment imaging compared to open radical nephrectomy. Although possibly associated with lower morbidity, thermal ablation is associated with significantly greater use of imaging compared to other small renal mass treatments. This may increase costs and radiation exposure, although further study is needed for confirmation.

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