Jed-Sian Cheng

Prostato-symphyseal Fistula After Photoselective Vaporization of the Prostate: Case Series and Literature Review of a Rare Complication

OBJECTIVE To report our experience with the management of prostato-symphyseal fistula (PSF) after photoselective vaporization (PVP) or transurethral resection of the prostate (TURP) and review cases of this complication in published reports. MATERIALS AND METHODS We report the management of 3 patients with PSF after PVP at our institution. A total of 5 published cases of PSF after PVP or TURP were identified from the National Library of Medicine MEDLINE database. A total of 8 patients were reviewed. RESULTS Overall, the mean age was 71 years (range, 50-83 years), and average follow-up was 4.3 months (range, 1-7 months). Mean prostate volume was 32 mL (range, 16-38 mL). Five patients developed PSF after PVP and 3 patients after TURP. The most common postoperative symptoms included difficulty ambulating (100%) and pelvic, groin, and/or lower abdominal pain (85%). Associated diagnoses included osteitis pubis (38%) and urinoma (50%). Infectious complications were urinary tract infection (25%), osteomyelitis (38%), and infected urinoma (38%). Average time to diagnosis of PSF was 3.5 months (range, 0.5-11 months). Operative intervention was necessary in 75% of patients. CONCLUSION This is the first reported case series on the management of PSF after PVP or TURP. This complication can be difficult to diagnose, manage, and may cause significant patient morbidity. Management requires a multidisciplinary approach. Patients commonly present with non-urologic symptoms leading to a delay in diagnosis. Further studies are needed to assess the incidence and optimal management of this complication.

Primary genitourinary melanoma: Epidemiology and disease-specific survival in a large population-based cohort

BACKGROUND Primary genitourinary (GU) melanoma is a rare disease, which is poorly characterized. OBJECTIVE To examine clinical characteristics and survival outcomes of primary GU melanoma among men and women. DESIGN, SETTING, AND PARTICIPANTS Retrospective study using the Surveillance, Epidemiology, and End Results database (1973-2010) was used to identify primary GU melanoma cases by tumor site and histology codes. We examined associations of GU melanoma with demographic, clinical, and pathologic characteristics, as well as disease-specific survival (DSS). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS DSS was calculated using the Kaplan-Meier method. Cox-proportional hazard models were used to calculate hazard ratios and 95% CI for factors associated with worse DSS. RESULTS AND LIMITATIONS A total of 1,586 histologically confirmed cases of primary GU melanoma were identified with a median age of 66.1 years (IQR: 55-80). Incidence of primary GU melanoma was 0.2cases/million among men and 1.80cases/million among women. Overall, 60.1% of patients had localized disease at presentation and 90.5% of patients had cancer-directed surgery. Patients with urothelial melanoma had the worst 5- and 10-year DSS (39% and 29%, respectively). Women with vulvar/vaginal melanoma had worse 5- and 10-year DSS compared to men with penile/scrotal melanoma. In multivariate analysis, decreased survival was associated with increasing age, distant stage, and lymph node involvement. Results are limited by the lack of standardized staging for primary GU melanoma and the retrospective design of our study. CONCLUSIONS Patients with primary GU melanoma present with advanced stage and have a poor prognosis. Women have worse DSS compared to men. DSS is negatively associated with advanced age at diagnosis, higher stage, and lymph node involvement. PATIENT SUMMARY Clinicians and patients must be aware of the poor disease-specific outcomes associated with primary GU melanoma. Most importantly, women fare worse than men and mucosal melanomas have worse outcomes compared to cutaneous melanomas.

Maximally Invasive Ablation Versus Minimally Invasive Partial Nephrectomy

Renal preservation techniques have become prevalent and favored in managing incidental small renal masses (SRMs). Currently, the minimally invasive partial nephrectomy (MIPN) is a standard for the treatment of SRMs. The comparison of MIPN and laparoscopic renal cryoablation (LRC) in this article by Fossati et al is not the most practical [1]. The development of percutaneous ablation techniques such as radiofrequency ablation (RFA) and cryoablation have mostly supplanted the use of LRC. The authors alluded to the fact that LRC patients tended to be older and sicker and thus selected for ablation. Would it then not make sense to perform a less invasive procedure on these sicker patients? A percutaneous ablation would bypass the need for general anesthesia and the need to insufflate the abdomen with pneumoperitoneum. If one were to go through the trouble of laparoscopic dissection of the kidney for an SRM, it would not take much time to perform an MIPN. In fact, the operative times in this study were essentially equivalent. More surprisingly, the blood loss was significantly greater in the LRC group [1]. It is hard to determine whether these are just comparisons because a number of factors have not been well evaluated. Nephrometry scoring [2] and PADUA scoring [3] are necessary to determine the relative difficulty of a renal mass for an intervention. Not having these complexity scores represents a significant knowledge gap; they might have provided more insight into the interventions described. Moreover, inclusion of the learning curve of the surgeons and for which procedures (laparoscopic partial nephrectomy, robotic partial nephrectomy, or LRC) was not well detailed and could have affected many of the measured outcomes. Selection bias has not been well accounted for in

Abstract A45: The association between type 2 diabetes mellitus and incidence of renal cell carcinoma (RCC) and fatal RCC in two prospective cohorts

Introduction: Current epidemiologic evidence suggests that type 2 diabetes (T2D) is associated with an increased risk of renal cell carcinoma (RCC), but no prospective studies have explored the association in both men and women. Postulated mechanisms include hyperinsulinemia, increases in circulating growth factors, increased endogenous estrogens, and changes in glucose availability. Given the increasing incidence of T2D it is imperative to further evaluate its role in RCC incidence. Methods: We investigated the association between T2D and RCC using prospective cohorts of 117,616 women from the Nurses9 Health Study (NHS) and 48,818 men from the Health Professionals Follow-up Study. Self-reports of physician-diagnosed diabetes were collected at baseline, updated biennially, and confirmed via supplemental questionnaires. We used multivariable Cox proportional hazards models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the incidence of both total and fatal pathology-confirmed RCC. Models were adjusted for BMI, hypertension, smoking, alcohol intake, NSAID use, and physical activity. Additional adjustment for race, fruit, and vegetable intake did not affect results. Results: During 34 years of follow-up in the NHS we confirmed 309 cases of RCC, including 60 fatal cases. During 24 years of follow-up in the HPFS we confirmed 214 total cases, including 34 fatal cases. In women, T2D was associated with a significantly increased risk of incident RCC (multivariable HR 1.55; 95%CI 1.08 – 2.19), but not fatal RCC (multivariable HR 0.74; 95%CI 0.22 – 2.48). In men, T2D was not associated with an increased risk of incident RCC (multivariable HR 1.10; 95%CI 0.65 – 1.86), but men with T2D were at a non-significantly higher risk of fatal RCC (multivariable HR 2.89; 95%CI 0.93 – 9.02). Compared to non-diabetic women, the association between T2D and RCC was non-significantly stronger in women with a shorter duration of T2D (multivariable HR for ≤ 5 years: HR 2.11; 95%CI 1.31 – 3.38; for > 5 years: HR 1.23; 95%CI 0.77 – 1.95; pdiff: 0.58). In men, duration of T2D was not associated with an increased risk of incident RCC. Conclusions: Our results support previous findings of an association between T2D and incidence of RCC in women; however, we found no significant association in men. T2D may be associated with an increased risk of fatal RCC in men, though power for this analysis in men and women was low. Citation Format: Rebecca E. Graff, Alejandro Sanchez, Jed-Sian Cheng, Dayron Rodriguez, Adam S. Feldman, Glen Barrisford, Seth Bechis, Michael L. Blute, Meir Stampfer, Mark A. Preston, Kathryn M. Wilson, Eunyoung Cho. The association between type 2 diabetes mellitus and incidence of renal cell carcinoma (RCC) and fatal RCC in two prospective cohorts. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A45.

Abstract LB-279: Nonsteroidal anti-inflammatory drug (NSAID) use and risk of lethal renal cell carcinoma

Proceedings: AACR Annual Meeting 2014; April 5-9, 2014; San Diego, CA Background: Studies suggest that non-steroidal anti-inflammatory drug (NSAID) use may increase risk of renal cell cancer (RCC), but the relationship to the lethal form of RCC remains unknown. Methods: We examined the relationship between NSAID use and RCC risk in two large prospective cohorts: the Nurses’ Health Study and the Health Professionals Follow-up Study. Use of aspirin and other NSAIDs was ascertained in 1990 in the Nurses’ Health Study and in 1986 in the Health Professionals Follow-up Study, and every 2 years thereafter. We evaluated baseline use and duration of NSAID use. We defined the lethal form of RCC as RCC that resulted in death due to the disease. Results: During follow-up of 18 years among 77,524 women and 20 years among 49,403 men, we documented 364 cases of RCC, of which 102 were fatal. Regular use of non-aspirin NSAIDs was associated with an increased overall RCC risk; there was a dose-response relationship between duration of non-aspirin NSAID use and RCC risk; compared with non-regular use, the pooled multivariable relative risks (RRs) were 0.78 (95% CI, 0.58-1.06) for use of less than 4 years, 1.29 (95% CI, 0.95-1.74)) for 4 to less than 10 years, and 2.21 (95% CI 1.39-3.49) for use for 10 or more years (P for trend, 0.0006). Furthermore, non-aspirin NSAID users of 4-10 years (pooled multivariable RR 3.13, 95% CI 1.70-5.77) and more than 10 years (pooled multivariable RR 7.23, 95% CI 2.51-20.83) had a significantly increased risk of lethal RCC. Aspirin use was not associated with increased risk of overall (pooled multivariable RR 1.07, 95% CI 0.84-1.34) or lethal RCC (pooled multivariable RR 1.59, 95% CI 0.85-2.96). Conclusion: Our prospective data suggest that non-aspirin NSAID use is associated with an increased incidence of RCC, especially the lethal form of RCC. Citation Format: Mark A. Preston, Jed-sian Cheng, Glen Barrisford, Alex Sanchez, Adam S. Feldman, Dayron Rodriguez, Toni K. Choueiri, Meir Stampfer, Walter C. Willett, Eunyoung Cho. Nonsteroidal anti-inflammatory drug (NSAID) use and risk of lethal renal cell carcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-279. doi:10.1158/1538-7445.AM2014-LB-279