Scott Tennant

There will always be a place for laboratory research in andrology, but the past year has been one of surgical advancements for those who diagnose and treat male infertility. 

"There are certain things that always seem to be part of the conversation on the latest and greatest in andrology, but this year it seems that surgical developments are taking center stage," said Dr. Niederberger. 

A team of Canadian researchers is set to report the results of a large series of men suggesting that favorable semen parameters, patency, and pregnancy rates can be realized in men whose vasectomies occurred more than 10 years earlier-provided the surgeon is proficient in both vasovasostomy and epididymovasostomy. 

Speaking of technique, an American group will report surgical outcomes showing that while the probability of needing an epididymovasostomy (unilateral or bilateral) increases with vasectomy age, it does not go up indefinitely. After 2 decades or so, the need for bilateral vasovasostomy makes a resurgence. 

"The moral of the story is that old expectations about the chances of a successful vasectomy reversal decreasing over time aren't necessarily true," Dr. Niederberger said. "After a certain point, they may actually start to get better. 

Articles

There will always be a place for laboratory research in andrology, but the past year has been one of surgical advancements for those who diagnose and treat male infertility.

Surgical developments take center stage in andrology

-AUA has formed a task force to create a pool of qualified surgeons who will teach and perform male circumcisions to help prevent the spread of HIV infection in sub-Saharan Africa, the association recently announced. 

The task force will work to link its volunteer surgeons with various African ministries of health and with international health agencies in need of physicians qualified to perform circumcisions. AUA will offer a training course for potential volunteers at its 2010 annual meeting in San Francisco. 

"The Male Circumcision Task Force was formed at the request of the AUA board of directors after the role of male circumcision in reducing the spread of HIV infection was proven by three prospective randomized clinical trials in Africa," said Ira Sharlip, MD, clinical professor of urology at the University of California, San Francisco and chair of the task force. 

Indeed, numerous studies have suggested that male circumcision reduces the risk of HIV acquisition. Dr. Sharlip highlighted the three recent clinical trials, all of which showed that male circumcision produced substantial reductions in HIV infection in heterosexual African men: 

Dr. Sharlip noted that African nations with high prevalence of HIV disease and low prevalence of circumcision include Botswana, Kenya, Lesotho, Namibia, South Africa, Swaziland, and Uganda, among others. 

 The training course at the AUA annual meeting is for potential volunteers. It is designed for board-eligible/board-certified urologists and residents interested in traveling to Africa for 2 to 4 weeks of volunteer service. The free, non-CME course will be held twice during the meeting: Monday, May 31, from 1 pm to 3 pm; and Tuesday, June 1, from 1 to 3 pm. 

"The course will cover such topics as the epidemiology of circumcision and of HIV, techniques of male circumcision and local anesthesia, why male circumcision is effective for HIV prevention, elements of an effective HIV prevention program, challenges of circumcision training in Africa, cultural sensitivity, what to expect at the African sites, how to be a good teacher and ambassador, and AUA requirements for volunteers," Dr. Sharlip said. 

Volunteers-who will have all of their trip-related expenses paid-will travel to various nations in sub-Saharan Africa. Dr. Sharlip was unsure how many urologic surgeons would go over at one time, saying it depends largely on demand, though he did estimate that volunteers might perform between 20 and 50 procedures per day. 

AUA has formed a task force to create a pool of qualified surgeons who will teach and perform male circumcision to help prevent the spread of HIV infection in sub-Saharan Africa.

HIV prevention tackled by AUA circumcision task force

-The oral angiogenesis inhibitor pazopanib (Votrient) more than doubled progression-free survival versus placebo in a randomized, phase III trial of patients with advanced renal cell carcinoma. 

Among 435 patients randomly assigned 2:1 to receive either pazopanib, 800 mg once daily, or placebo, progression-free survival was 9.2 months in the pazopanib group and 4.2 months in the placebo arm (

The difference was even greater in the 233 treatment-naïve patients (11.1 vs. 2.8 months, 

<.0001), and was maintained among the 202 patients previously treated with cytokine therapy (7.4 vs. 4.2 months,

"Physicians should know that there is another option for the treatment of patients with advanced RCC," said lead author Cora Sternberg, MD, chief of medical oncology at San Camillo and Forlanini hospitals in Rome. "Treatment has improved in the past few years with the introduction of targeted therapies, but advanced RCC remains a challenging disease." 

The FDA approved pazopanib for treatment of advanced RCC in October 2009. The agent works by inhibiting endothelial growth factors (VEGFR-1, 2, and 3) and other tyrosine kinases (PDGFR-α, PDGFR-β, and c-kit). 

The objective response rate in the trial was 30% with pazopanib, compared with 3% with placebo (

<.001). Median duration of response was 1 year. 

Dr. Sternberg said pazopanib is currently being evaluated in comparison with other vascular endothelial growth factor inhibitors. An ongoing, phase III, open-label trial known as COMPARZ, for instance, is examining pazopanib versus sunitinib (Sutent) in 876 patients with metastatic clear-cell RCC and no prior treatment. In addition, another trial, known as PISCES, will address patient preferences between the two drugs. 

 Among patients in her group's pazopanib investigation, Dr. Sternberg said the medicine was "very well tolerated" and that its safety has been well characterized. The most common side effects were diarrhea (52%), hypertension (40%), hair color changes (38%), nausea (26%), weight loss (22%), and vomiting (21%). 

"The side effects are what one might expect with this class of agents," she said. 

Dr. Sternberg noted that the trial was the first placebo-controlled, phase III pazopanib study to include both treatment-naïve and cytokine-pretreated patients and show a significant improvement in progression-free survival in both groups. 

				She said the study had been intended only for cytokine-refractory patients, "but was rapidly amended after only a few patients were entered, as there was great interest for patients who were not cytokine-pretreated to participate."			

Three of the study's co-authors are employees of GlaxoSmithKline. 

The oral angiogenesis inhibitor pazopanib (Votrient) more than doubled progression-free survival versus placebo in a randomized, phase III trial of patients with advanced renal cell carcinoma.

Advanced kidney cancer progression slowed by oral therapy

The difference may be explained by the specialty of the physician that patients last saw before selecting treatment, say the authors of the multicenter study, which was published in 

Of the 559 men in the study, 315 (56%) received treatment in county hospitals, while 244 (44%) were treated in private facilities. "County hospitals," in this case, were defined as institutions primarily funded by local or state governments to care for otherwise underserved populations. 

The authors referred to their study as the first to compare prostate cancer treatments between private and public institutions. 

"I honestly would have hypothesized that there would be no difference between the two types of health care venues," said first author J. Kellogg Parsons, MD, assistant professor of surgery/urology at the University of California, San Diego. "And even when we subsequently adjusted for all of the confounders-like severity of cancer, age, and health status-we found that the association still held up." 

Men in the study were enrolled in a state-funded program for low-income patients known as IMPACT (Improving Access, Counseling, and Treatment for Californians with Prostate Cancer). There were no significant differences between the publicly and privately treated patients with respect to age, comorbidities, Gleason sum, T stage, or PSA. 

Provider specialty plays key role 							

 Dr. Parsons and his colleagues suspect that provider specialty played a substantial role in the outcomes. At county hospitals, patients were generally seen by urologic surgeons, whereas at private institutions, patients' initial points of contact were a mix of urologists, oncologists, and radiation oncologists. 

All patients in the study were offered a second opinion if they desired, but there was no way of tracking how many men actually took advantage of the offer. 

"As a specialty, urologists need to be very sensitive to the idea that patients need second opinions with different specialists," Dr. Parsons said. "So if the initial point of contact is a urologist, the patient should see a radiation oncologist, too. That should be built into the consultation paradigm. 

"That's important because prior research shows that some prostate cancer patients have significant regrets after undergoing treatment. If we're able to enhance preoperative counseling through access to multiple types of providers, we potentially may enhance post-treatment quality of life and reduce factors like treatment regret." 

Dr. Parsons pointed out that this question also deserves further scrutiny due to the fact that county hospitals are funded with taxpayer dollars, which means there are implications for health policy. 

"To be fair, as physicians we all carry certain intellectual biases," he said. "For example, when urologists look at published research comparing surgery and radiation, we may walk away with different conclusions than radiation oncologists simply because of our disparate training backgrounds. These conclusions, in turn, may influence the ways in which we counsel our patients." 

Dr. Parsons' group also found that participants treated by private providers were more likely to be Caucasian than those seen at county hospitals (35% vs. 10%, 

Low-income prostate cancer patients are far more likely to undergo surgery for their disease if they are treated in a county hospital versus a private provider.

Scott Tennant

Articles

Surgical developments take center stage in andrology

HIV prevention tackled by AUA circumcision task force

Advanced kidney cancer progression slowed by oral therapy

Prostate cancer treatment differs at county vs. private hospitals