The report by Shen and associates from University of California, San Francisco is one of the largest single-institution experiences in pheochromocytoma ever published. They describe a great diversity in the initial clinical manifestations encountered, with only a minority of patients presenting electively with classic signs and symptoms. The growing fraction of patients identified through incidental radiographic findings and known familial syndromes reflects the changing face of this disease and our increasing understanding of genotype-phenotype correlations. The fact that 14 patients presented in overt hemodynamic crisis likely reflects selective referral of high-risk patients to this established center of expertise. The 4 patients who required intra-aortic balloon counterpulsation are a reminder that pheochromocytoma can present with refractory cardiogenic shock. Despite these challenges, Shen and associates achieved a zero mortality rate in their series. Their work adds to the existing literature demonstrating that laparoscopic adrenalectomy is the procedure of choice for the treatment of pheochromocytoma.