Editorial Comment: The thiazolidinediones, pioglitazone and rosiglitazone, are peroxisome proliferator activated receptor g agonists that are used as oral medications for type 2 diabetes mellitus. Although effective, there have been safety concerns (eg rosiglitazone associated heart attack risk) and, specifically from a urological cancer standpoint, an associated increased bladder cancer risk. This meta-analysis examined more than 200 citations and extracted data from observational and randomized trials. The key epidemiological result was the longer the use and the higher the cumulative dose of pioglitazone, the greater the risk of bladder cancer. Taking pioglitazone for 12 to 24 months and longer than 24 months was associated with odds ratios of 1.4 and 1.5, respectively, of increased bladder cancer risk. For rosiglitazone there was no consistent relationship with bladder cancer development. Patients ask whether they should or should not take these and multiple other types of medications, many of which a physician may be unfamiliar with regarding efficacy or risk. For this type of agent a reasonable approach would be to advise patients that a small increased risk has been reported and the risk is related to how much medication one takes and the duration of administration. However, to stop categorically these important medications, especially without consulting the primary care physician or endocrinologist, would be a drastic and perhaps dangerous step. One should monitor patients who are taking these medications, especially if other risk factors exist. Sam S. Chang, MD

Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Risk of Fracture after Radical Cystectomy and Urinary Diversion for Bladder Cancer A. Gupta, C. L. Atoria, B. Ehdaie, S. F. Shariat, F. Rabbani, H. W. Herr, B. H. Bochner and E. B. Elkin University of Iowa, Iowa City, Iowa, Memorial Sloan Kettering Cancer Center, New York and Albert Einstein College of Medicine, Bronx, New York, and Medical University of Vienna, Vienna, Austria J Clin Oncol 2014; 32: 3291e3298.

Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.061 available at http://jurology.com/ Editorial Comment: This analysis of the SEER (Surveillance, Epidemiology and End Results)Medicare data set identifies an important heretofore unrecognized side effect of cystectomy and urinary diversion. Specifically the authors note that patients undergoing these procedures had a 21% greater risk of fracture following the operation, despite the fact that these patients had fewer comorbid conditions and were less likely to report a prior fracture than patients with bladder cancer who did not undergo cystectomy (controls). The authors postulate that this increased risk of fracture is related to the chronic metabolic acidosis that occurs after urinary diversion. This theory certainly makes scientific sense and supports the validity of this observation. Practicing urologists need to be aware of these results, and need to include increased risk of osteoporosis and fracture as a possible long-term complication of cystectomy when counseling patients in the preoperative setting. David F. Penson, MD, MPH

Re: Risk of fracture after radical cystectomy and urinary diversion for bladder cancer.

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