253Archivio Italiano di Urologia e Andrologia 2017; 89, 4 ORIGINAL PAPER Risk factors for benign prostatic enlargement: The role of lifestyle habits at younger age. The #Controllati2017 initiative study group Vincenzo Mirone 1, Giuseppe Carrieri 2, Giuseppe Morgia 3, Luca Carmignani 4, Giuseppe Vespasiani 5, Fabio Parazzini 6, Walter Artibani 7 1 Università degli Studi di Napoli Federico II, UOC di Urologia della A.O.U. Federico II Napoli, Italy; 2 Dipartimento Nefro/Urologico Clinica Urologica e Centro Trapianti di Rene, Università degli Studi di Foggia, Italy; 3 Università degli Studi di Catania Presidio Ospedaliero Policlinico, Catania, Italy; 4 Università degli Studi di Milano, Divisione Universitaria di Urologia, IRCCS Policlinico San Donato Milano, Italy; 5 UOC Urologia, Fondazione PTV - Policlinico Tor Vergata, Roma, Italy; 6 Università degli Studi di Milano Dipartimento di Scienze Cliniche e di Comunità, IRCCS Policlinico, Milano, Italy; 7 Azienda Ospedaliera Universitaria Integrata, Verona, Italy. Objective: The risk factors for benign pro- static enlargement (BPE) are not well understood and particularly few data are available from Italian population. Materials and methods: This was an observational cross sec- tional study aimed to examine the association between sever- al risk factors and BPE. During the “#Controllati2017” ini- tiative, men aged 18 years or more were invited to attend participating urologic centers for a free of charge visit for counseling about urologic or andrologic conditions. Each par- ticipating man underwent a physical examination including digital rectal examination (DRE). Further he was asked about his medical history, urologic symptoms, sexual activity and related problems. Diagnosis of BPE was made by the urologist after DRE. Results: Out of the 1902 [mean age 54 years (SD 12, range 18-92)] considered men, a total of 603 subjects (31.7%) had diagnosis of BPE. The diagnosis of BPE increased from 9.3% in men aged < = 50 years, to 34.1% in those aged 51-60 years and to 58.7% among men aged > 60 years. A history of hypertension, diabetes, heart diseases, hypercholesterolemia and hypertriglyceridemia were all significantly associated with an increased risk of BPE in the total series and, although not always in a statistically significant way, in strata of age. Physical activity (PA) was significantly associ- ated with a decreased risk of BPE. We have further analyzed the risk of BPE in men with one or more of the identified risk factors (i.e. hypertension, diabetes, heart disease, hypercho- lesterolemia, hypertriglyceridemia and low PA): the risk of BPE increased with number of risk factors reported by the subjects. The estimated risk were higher among younger men. Conclusion: In our study a history of hypertension, diabetes, heart disease, hypercholesterolemia and hypertriglyc- eridemia increased the risk and physical activity lowered the risk of BPE. This risk profile was observed also in men aged < 50 years. KEY WORDS: Benign prostatic enlargement (BPE); Hypertension; Diabetes; Hearth disease; Hypercholesterolemia; Hypertriglyceridemia; Physical activity. Submitted 29 November 2017; Accepted 8 December 2017 Summary No conflict of interest declared. INTRODUCTION Despite the high prevalence of the conditions, the risk factors for benign prostatic hyperplasia (BPH) or benign prostatic enlargement (BPE) are not well understood. Some studies have suggested a role of diabetes or hyper- tension in the pathogenesis of PBH (1). Further, HDL-cholesterol levels were an independent pre- dictors of prostate enlargement (2). Other studies have shown that body mass index and waist circumference were positively related with prostate volume (3, 4). All these fac- tors are associated with metabolic syndrome, a condition that increase the risk of cardiovascular diseases (5). Further, it has been suggested that regular physical activ- ity (PA) may decreased the risk of BPE (6). These findings suggest that healthy life habits may lower the risk of growth of prostatic volume. Available data on the role of these factors are scanty and particularly few data are available from Italian pop- ulation. In June 2017, the Italian Society of Urology conducted the “#Controllati2017” preventive initiative. In the frame- work of this preventive campaign, data have been col- lected on determinants of the risk of BPE. MATERIALS AND METHODS This was an observational cross sectional study aimed to examine the association between several risk factors and BPE. During the “#Controllati2017” (1st June-15th July 2017) initiative, males of any age were offered to attend a free of charge visit for counseling about urologic or andro- logic conditions in urological centers affiliated to the Italian Society of Urology (Società Italiana di Urologia). A pamphlet inviting men for a free of charge check-up and listing participating centers was left in chemists and general practitioners’ waiting rooms; an advertising cam- paign was set in the press and broadcast media. Each participating man underwent a physical examina- tion including digital rectal examination (DRE) and was DOI: 10.4081/aiua.2017.4.253 Mirone_Stesura Seveso 03/01/18 12:12 Pagina 253 Archivio Italiano di Urologia e Andrologia 2017; 89, 4 V. Mirone, G. Carrieri, G. Morgia, L. Carmignani, G. Vespasiani, F. Parazzini, W. Artibani 254 asked by the urologist about his medical history, urolog- ic symptoms, sexual activity and related problems. A total of 173 centers participated to the initiative. Epidemiological data were collected in 61 centers for a total of 2572 men who filled the questionnaire. Data were recorded with a simple questionnaire used by all centers. The first section, about age and life habits was complet- ed by the patient. History of hypertension, diabetes, hearth diseases and other medical conditions, and the findings of the clinical examination were recorded by the urologist. Diagnosis of BPE was made by the urologist after DRE. Erectile dysfunction (ED) was diagnosed according to the definition of the NIH Consensus Development Panel (7). The 2002 International Continence Society definitions were used for frequency, nicturia, urgency, dysuria (intermittency, slow stream, straining, terminal dribble, postmicturition dribble) incomplete emptying (8). The section on PA included questions on self reported intensity of activity at work and in leisure time separately. Patients were asked about their PA, which were classified into five categories (scores between 1 and 5) correspon- ding to ‘very heavy’, ‘heavy’, ‘average’, ‘moderate’ and ‘light’. The scores of the two highest levels of occupational and leisure PA were combined, in order to obtain adequate numbers in the categories. For the purpose of the present paper we compared the characteristics of subjects with and without BPE. Mean (standard deviation, SD), median (range) or fre- quency (percent,%) were computed as appropriate. Odds ratios (OR), and the corresponding 95% confidence intervals (CI), were derived using unconditional multi- ple logistic regression, fitted by the method of maxi- mum likelihood, in which the dependent variable was the presence (case) or absence (control) of BPE and the independent ones were the exposures considered in the analysis. We included in the model potential co-variates Table 1. Distribution of 603 subjects with and 1299 without benign prostatic enlargement according to selected factors and strata of age. ≤ 50 years 51-60 years ≥ 61 years No BPE BPE adj OR No BPE BPE adj OR No BPE BPE adj OR Total series N = 681 N = 70 (95% CI) N = 382 N = 198 (95% CI) N = 236 N = 335 (95% CI) OR (95% CI) (90.7) (9.3) (65.9) (34.1) (41.3) (58.7) BMI (kg/m2) < 25 340 (50.9)* 35 (50.7) 1 154 (41.1) 61 (31.6) 1 87 (37.3) 116 (35.4) 1 1 ≥ 25 - < 30 254 (38.0) 25 (36.2) 1.0 (0.6-1.6) 168 (44.8) 95 (49.2) 1.4 (1.0-2.1) 117 (50.2) 152 (46.3) 1.0 (0.7-1.9) 1.4 (1.1-1.7) ≥ 30 74 (11.1) 9 (10.8) 1.2 (0.5-2.6) 53 (14.1) 37 (19.2) 1.2 (0.6-2.2) 29 (12.4) 60 (18.3) 1.55 (0.9-2.6) 1.9 (1.4-2.5) Smoking habits Never smokers 391 (58.1) 34 (48.6) 1 195 (51.3) 87 (43.9) 1 102 (43.8) 140 (42.3) 1 1 Ever smokers 282 (41.9) 36 (51.4) 1.5 (0.8-2.7) 185 (48.6) 111 (56.1) 1.3 (0.8-2.0) 131 (56.2.) 191 (57.7) 1.1 (0.7-1.7) 1.4 (0-9-1.8) Occupational PA No 122 (18.9) 13 (21.0) 1 77 (21.9) 36 (19.6) 1 43 (22.3) 73 (28.2) 1 1 Low 203 (31.4) 20 (32.3) 0.9 (0.4-1.9) 112 (31.9) 56 (30.4) 1.1 (0.7-1.8) 54 (28.0) 82 (31.7) 0.9 (0.5-1.9) 0.9 (0.6-1.1) Moderate 193 (29.8) 23 (37.1) 1.1 (0.6-2.3) 108 (30.8) 62 (33.7) 1.2 (0.7-2.0) 79 (40.9) 80 (30.9) 0.6 (0.4-1.0) 0.8 (0.7 -1.1) Intense 129 (19.9) 6 (9.7) 0.4 (0.2-1.2) 54 (15.4) 30 (16.3) 1.2 (0.7-2.2) 17 (8.8) 24 (9.3) 0.8 (0.4-1.7) 0.6 (0.4-0.9) Leisure PA No 61 (9.1) 5 (7.9) 1 40 (11.0) 30 (16.2) 1 27 (12.3) 41 (12.9) 1 1 Low 195 (29.2) 20 (31.8) 1.3 (05-3.5) 115 (31.7) 51 (27.6) 0.6 (0.3-1.1) 62 (28.2) 90 (28.4) 1.0 (0.5-1.7) 0.7 (0.5-1.0) Moderate 285 (42.6) 29 (46.0) 1.2 (0.5-3.3) 157 (43.2) 70 (37.8) 0.6 (0.3-1.0) 97 (44.1) 152 (48.0) 1.0 (0.6-1.8) 0.8 (0.6-1.1) Intense 128 (19.1) 9 (14.3) 0.9 (0.3-2.8) 51 (14.0) 34 (18.4) 0.9 (0.5-1.7) 34 (15.4) 34 (10.7) 0.7 (0.3-1.3) 0.6 (0.4-0.9) Hypertension No 595 (90.6) 50 (76.9) 1 256 (70.0) 106 (56.7) 1 118 (51.8) 150 (45.7) 1 1 Yes 62 (9.4) 15 (23.1) 2.9 (1.5-5.4) 110 (30.0) 81 (43.3) 1.8( 1.2-2.6) 110 (48.2) 178 (54.3) 1.2 (0.9-1.8) 3.1 (2.5-3.8) Diabetes No 652 (99.2) 62 (98.4) 1 341 (95.0) 164 (90.6) 1 198 (89.2) 266 (83.4) 1 1 Yes 5 (0.8) 1 (1.6) 2.1 (0.2-18.3) 18 (5.0) 17 (9.4) 2.0 (1.0-3.9) 24 (10.8) 53 (16.6) 1.6 (0.9-2.8) 3.7 (2.5-5.4) Hearth disease No 650 (99.1) 61 (96.8) 1 332 (93.3) 164 (91.1) 1 189 (87.5) 245 (79.8) 1 1 Yes 6 (0.9) 2 (3.2) 3.6 (0.7-18.0) 24 (6.7) 16 (8.9) 1.2 (0.7-2.6) 27 (12.5) 62 (20.2) 1.8 (1.1-2.9) 3.5 (2.5-5.0) Hypertriglyceridaemia No 601 (91.9) 57 (87.7) 1 302 (86.0) 152 (85.4) 1 181 (85.8) 257 (84.3) 1 1 Yes 53 (8.1) 8 (12.3) 1.6 (0.7-3.5) 49 (14.0) 26 (14.6) 1.1(0.6-1.8) 30 (14.2) 48 (15.7) 1.1 (0.7-1.9) 1.4 (1.1-1.9) Hypercholesterolaemia No 533 (81.0) 49 (74.2) 1 263 (73.9) 122 (67.4) 1 157 (71.7) 212 (68.0) 1 1 Yes 125 (19.0) 17 (25.8) 1.5 (0.8-2.7) 93 (26.1) 59 (32.6) 1.4 (0.9-2.0) 62 (28.3) 100 (32.0) 1.2 (0.8-1.7) 1.6 (1.3-2.0) OR: odds ratio; CI: confidence interval; *In some cases the sum does not add up the total due to missing values. Mirone_Stesura Seveso 03/01/18 12:12 Pagina 254 considered as categorical variables. The terms included in the model were those found statistically significantly associated with the risk of BPE in the crude analysis. Further, we computed an overall risk score including all factors found statistically significantly associated with the risk of BPE in the crude analysis of the total series. Subjects were classified according the presence of none, 1,2 3 or more factor and corresponding OR were com- puted. RESULTS Overall, 2572 men were observed in 61 participating centers: the mean number of attending men per center was 42 (median 35, range 4-126). Their mean age was 54 years [standard deviation (SD) 12, range 18-92]. After exclusion of men who did not filled the demo- graphic questionnaire and those who underwent previ- ous partial and complete prostatectomy, we analyzed data from 1902 men, aged 54 years (SD 12, range 18- 92). The reason for the visit was urinary symptoms in 318 (16.7%), sexual problems in 234 (12.3%), renal disease in 37 (2.0%) and prostatic problems in 346 (18.2%). Prevention was the only reason for consultation in 1156 subjects (60.8%, each man could indicate one reason or more). Out of the 1902 considered men, a total of 603 subjects (31.7%) had diagnosis of BPE. The diagnosis of BPE increased from 9.3% in men aged <=50 years, to 34.1% in those aged 51-60 years and to 58.7% among men aged > 60 years. The general characteristics of study sub- jects according to the diagnosis of BPE according to class age are shown in Table 1. A history of hypertension, diabetes, hearth disease, hyper- cholesterolemia and hypertriglyceridemia were all signifi- cantly associated with an increased BPE risk in the total series and, although not always in a statistically significant way, in all the three considered strata of age. PA was sig- nificantly associated with a decreased risk of BPE. We have further analyzed the risk of BPE in men with one or more of the identified risk factors (i.e. hypertension, diabetes, hearth disease, hypercholesterolemia and hyper- triglyceridemia and PA): the risk of BPE increased with number of risk factors reported by the subjects. The esti- mated OR were higher among younger men (Table 2). Table 3 considers the frequency of urinary symptoms among men with a diagnosis of BPE in strata of age. The frequency of all symptoms increased with age and dysuria was the most common symptoms at all ages. Considering subjects for which the information was available, ED was reported in the 39,8% (225/565) of men with BPE and 16.3% (201/1235) of those without BPE (adj chi suare p < 0.05). This difference in the fre- quency of DE was consistent in the three considered stra- ta of age: in particular considering men aged < 50 years the frequency of ED was 17.5% (11/63) among the men with BPE and 9.9% (64/644) among those without BPE (adj chi square = 0.06). DISCUSSION The general results of this analysis show that a history of hyperten- sion, diabetes, hearth disease, hypercholesterolemia and hyper- triglyceridemia increase the risk of BPE at all ages. A regular PA tended to decrease the risk. Interestingly these factors were associated with PBE risk also in men aged 50 years or less, thus underlining the role of a healthy life style among younger men. This suggestion was also confirmed when we have con- sidered the risk BPE among men with one, two or three of the factors found associated with the risk of PBE: the presence of more risk factors was more markedly associ- 255Archivio Italiano di Urologia e Andrologia 2017; 89, 4 Risk factors for benign prostatic enlargement Table 2. Association between benign prostatic enlargement (BPE) and number of risk factors. ≤ 50 years 51-60 years ≥ 61 years Total series No BPE BPE adj OR No BPE BPE adj OR No BPE BPE adj OR adj OR N = 681 N = 70 (95% CI) N = 382 N = 198 (95% CI) N = 236 N = 335 (95% CI) (95% CI) (90.7) (9.3) (65.9) (34.1) (41.3) (58.7) Number of risk factors reported by the subject 0 494 (72.5) 42 (60.0) 1 187 (49.0) 72 (36.4) 1 82 (34.8) 95 (28.4) 1 1 1 134 (19.7) 17 (24.3) 1.8 (0.8-3.3) 122 (31.9) 75 (37.9) 1.7 (1.1-2.6) 81 (34.3) 105 (31.3) 0.9 (0.6-1.6) 1.3 (1.0-1.8) 2 38 (5.6) 7 (10.0) 2.3 (0.8-6.7) 44 (11.5) 31 (15.7) 1.9 (1.0-3.4) 43 (18.2) 78 (23.4) 1.1 (0.6-1.9) 1.5 (1.0-2.2) ≥ 3 15 (2.2) 4 (5.7) 3.5 (1.0-11.6) 29 (7.6) 20 (10.1) 2.0 (1.0-4.1) 30 (12.7) 57 (17.0) 1.9 (1.0-3.7) 2.1 (1.4-3.3) AOR: adjusted odds ratio. Including terms for BMI and age. Table 3. Association between benign prostatic enlargement (BPE) and urinary symptoms. ≤ 50 years 51-60 years ≥ 61 years No BPE BPE No BPE BPE No BPE BPE No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) Urgency 96 (14.1)* 10 (14.3) 28 (7.3) 32 (16.2) 11 (4.7) 52 (15.5) Nicturia 52 (7.6) 17 (24.3) 47 (12.3) 61 (30.8) 33 (14.0) 115 (34.3) Dysuria 86 (12.6) 38 (51.4) 92 (24.1) 108 (54.5) 74 (31.4) 212 (63.3) Frequency 46 (6.8) 27 (38.6) 48 (12.7) 79 (39.9) 24 (10.2) 131 (39.1) Incomplete voiding sensation 70 (10.3) 32 (45.7) 54 (14.1) 80 (40.4) 26 (11.0) 142 (42.4) *In some cases the sum does not add up the total due to missing values. Mirone_Stesura Seveso 03/01/18 12:12 Pagina 255 Archivio Italiano di Urologia e Andrologia 2017; 89, 4 V. Mirone, G. Carrieri, G. Morgia, L. Carmignani, G. Vespasiani, F. Parazzini, W. Artibani 256 ated with the risk of BPE in men aged 50 years or less. The role of modifiable lifestyle factors on the risk of BPH has been widely suggested (9). For example, a review of the literature conducted in the late 2000 and including eight studies has shown, compared to the sedentary group, a pooled odds ratios for BPH or LUTS of 0.70 (95% CI 0.44-1.13, p = 0.14), 0.74 (95% CI 0.60-0.92, p = 0.005), and 0.74 (95% CI 0.59-0.92, p = 0.006) for men engaging in light, moderate, and heavy physical activity, respectively (6). We confirm these findings, in particular the protective effects of PA was more evident among younger men. Obesity, elevated fasting plasma glucose, diabetes, dys- lipidemia, and the metabolic syndrome may all signifi- cantly increase the risks of BPH and low urinary tract symptoms (10-12). In our study diabetes, hypercholes- terolemia, hypertrigliceridemia were associated with an increased risk of BPE. Further a history of hypertension and hearth diseases increased the risk. All these findings underline that BPE shares similar risk factor with meta- bolic syndrome and cardiovascular diseases. The biological link between these risk factors and the prostatic growth is not completely understood. However, for example, it has been shown that lipids (oxi- dized low-density lipoprotein, LDL) increase in vitro the secretion of growth and pro-inflammatory factors by human stromal BPH cells in culture (13). Along this line in a clinical perspective, the addition of statins to stan- dard therapy for BHP lowered prostate volume (14). It has been suggested that metabolic syndrome-depend- ent prostate growth may play a major role among older men (15). An interesting findings of the present study is the observation that the OR of BPE associated with the presence of several risk factors such as PA and hyperlipi- demia, diabetes and hypertension were higher (although no statistically significantly different) among younger than older men. This findings underline the role of encouraging healthy lifestyle habits among men under the 50 years of age in order to reduce the risk of BPH. Limits As previously discussed in the paper reporting the results of the #Controllati2016 initiative (16), the major flaw of this study is the fact that the study population were men voluntarily presenting to the participating centers and physicians associated to the Italian Society of Urology (SIU). Along this line the observed frequency of BPE in this population, about 30%, is higher than reported in the literature (17). Further, the participating centers were not randomly identified among all members, so they cannot be consid- ered representative of all Italian centers. However, they were well distributed over the main areas of the country and there were no marked differences in the results among centers in various large Italian areas, giving strong support to the consistency of the general results. Likewise, the prevalence of hypertension and diabetes and overweight were largely similar to the general Italian population. For example the percentage of hypertensive subjects was largely consistent with that of the Italian population (18) and with the results of the #Controllati2016 survey (16). In any case, any inference from the present analysis must be made in strictly comparative terms and strictly referred to men attending urologic services. The diagnosis of BPE was based on DRE that tends to underestimate the prostatic volume (17). In any case any misclassification of men with or without BPE should lower the observed associations. The strengths of the study included the fact that it pro- vides information from a large series of men identified in all parts of Italy. Further, the participation rate was very high. Along this line, the patients presented themselves voluntarily to the physician, so their answers to all ques- tions should be truthful. CONCLUSIONS In our study a history of hypertension, diabetes, hearth disease, hypercholesterolemia and hypertriglyceridemia increased the risk and physical activity lower the risks of BPE. These findings are consistent with other studies. The find- ings suggest that BPE risk is associated with lifestyle habits and modifiable risk factors of cardiovascular disease. Cohort studies are needed to evaluate if modification of lifestyle habits may change the natural history of BPH. ACKNOWLEDGEMENT The #Controllati2017 initiative was partially supported by an unconditional grant of Menarini. REFERENCES 1. Bourke JB, Griffin JP. Hypertension, diabetes mellitus, and blood groups in benign prostatic hypertrophy. Br J Urol. 1966; 38:18-23. 2. Nandeesha H, Koner BC, Dorairajan LN, Sen SK. Hyperinsulinemia and dyslipidemia in non-diabetic benign prostat- ic hyperplasia. Clin Chim Acta. 2006; 370:89-93. 3. Lee S, Min HG, Choi SH, et al. Central obesity as a risk factor for prostatic hyperplasia. 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Passi surveillance http://www.epicentro.iss.it/passi/dati/cardio- vascolare.asp, last access November 17th 2017. 257Archivio Italiano di Urologia e Andrologia 2017; 89, 4 Risk factors for benign prostatic enlargement Correspondence Vincenzo Mirone, MD Università degli Studi di Napoli Federico II, UOC di Urologia della A.O.U. Federico II Napoli, Italy Giuseppe Carrieri, MD Dipartimento Nefro/Urologico Clinica Urologica e Centro Trapianti di rene, Università degli Studi di Foggia, Foggia, Italy Giuseppe Morgia, MD Università degli Studi di Catania Presidio Ospedaliero Policlinico, Catania, Italy Luca Carmignani, MD Università degli Studi di Milano, Divisione Universitaria di Urologia, IRCCS Policlinico San Donato Milano, Italy Giuseppe Vespasiani, MD UOC Urologia, Fondazione PTV - Policlinico Tor Vergata, Roma, Italy Fabio Parazzini, MD (Corresponding Author) Università degli Studi di Milano Dipartimento di Scienze Cliniche e di Comunità, IRCCS Policlinico, Milano, Italy fabio.parazzini@unimi.it Walter Artibani, MD Azienda Ospedaliera Universitaria Integrata Verona, Italy *The Controllati# study group: Abano Terme, Policlinico: A. Porreca; Acireale, P.O. S. Marta e S. Venera di Acireale Azienda Sanitaria Provinciale di Catania: A. Ingrassia; Acquaviva delle Fonti, Ente Ecclesiastico Ospedale Generale Regionale F. Miulli: G.M. Ludovico; Adria, Ospedale di Adria, ULSS5 Polesana: A. Meneghini; Agrigento, Ospedale San Giovanni di Dio: M. Ruppolo; Alba, Ospedale San Lazzaro: G. Fasolis; Altamura, Ospedale della Murgia Fabio Perinei: M. De Siati; Ancona, Ospedali Riuniti: A.B. Galosi; Andria, ASL BAT P.O. L. Bonomo: A. Corvasce; Arezzo, Ospedale San Donato: M. De Angelis; Avellino, Azienda Ospedaliera S. Giuseppe Moscati: V. Cicalese; Avellino, Casa di Cura Villa Esther: M. Di Martino; Baggiovara, Nuovo Ospedale Civile Sant'Agostino Estense: A. Mofferdin; Bari, Azienda Ospedaliera Policlinico di Bari - U.O. Urologia Universitaria 1: M. Battaglia; Bari, Azienda Ospedaliera Policlinico di Bari - U.O. Urologia Universitaria 2: P Ditonno; Bassano del Grappa, Ospedale Civile: A. Celia; Benevento, AO Gaetano Rummo: L. Salzano; Benevento, Casa di Cura Nuova Clinica Santa Rita: M. Coscione; Bergamo, Casa di Cura Palazzolo, P. Belvisi; Bologna, Azienda Ospedaliero - Universitaria di Bologna - Policlinico S. Orsola: E. Brunocilla; Borgomanero Ospedale SS Trinità: G. Monesi; Borgosesia, Ospedale S.S. Pietro e Paolo: G. Cipollone; Brescia, Presidio Ospedaliero: C. Simeone; Brindisi, Presidio Di Summa-Perrino: S. Brigante; Bussolengo, Ospedale ORLANDI di Bussolengo - UOC urologia AULSS 9 - Veneto: G. Pecoraro; Cagliari Ospedale SS Trinità: A. De Lisa; Campi Bisenzio, Ambulatori della Misericordia: F. Lunghi; Carpi, Ospedale Civile Ramazzini: M. Brausi; Casarano,Ospedale Ferrari: S. Raguso; Caserta, Azienda Ospedaliera Sant Anna e San Sebastiano di Caserta: S. Caggiano; Castelfranco Veneto, Ospedale San Giacomo Apostolo: L. De Zorzi; Castellammare di Stabia, Casa di Cura Villa Stabia:G. Scognamiglio; Castiglione del lago, Ospedale Civile: F. Balloni; Catania, Casa di Cura Gibiino: C. Ranno; Catania, Ospedale Garibaldi Nesima: P.G. La Rosa; Catania, Ospedale Vittorio Emanuele II: M. Falsaperla; Catania, Policlinico Gaspare Rodolico Clinica Urologica - Università di Catania: G. Morgia Catanzaro, Azienda Ospedaliera Universitaria Mater Domini: R. Damiano; Cesano Boscone, Casa di Cura Ambrosiana: F.Catanzaro; Chiari, ASST Franciacorta - Ospedale M. Mellini: L. Tralce; Chieti, Policlinico SS. Annunziata: L. Schips; Chieti, Università degli Studi Gabriele D'Annunzio: R. Tenaglia; Chieti, Villa Pini d’Abruzzo: G. Marascia; Città di Castello, Ospedale Civile: F. Balloni Città Sant’Angelo, Villa Serena: R. D’Andrea; Civitanova Marche, Ospedale Civile: E. Caraceni; Cosenza, Ospedale Civile P.O. Dell'Annunziata: F. Ventura; Cremona, Azienda Socio-Sanitaria Territoriale: C. Del Boca; Domodossola, Ospedale San Biagio: A. Rosa; Eboli, Ospedale Maria SS. Addolorata: A. Tufano; Enna, Azienda Sanitaria Provinciale 4 Enna - P.O. Umberto I: M. D’Anca; Fano, Azienda Ospedali Riuniti Marche Nord - Presidio Santa Croce di Fano: V. Beatrici; Feltre, Ospedale S. Maria del Prato- ULSS2: D. Xausa; Firenze, Ospedale AOU-Careggi: M. Carini, S. Serni; Foggia, Ospedali Riuniti: G. Carrieri; Foligno, Ospedale San Giovanni Battista: S. Parziani; Forlì, Ospedale G.B. Morgagni-Pierantoni: R. Gunelli; Frascati, Ospedale San Sebastiano: F. Carbonaro; Gallico- Reggio Calabria, ASL- Struttura Poliambulatoriale: M. De Martin Garbagnate Milanese, Ospedale Guido Salvini - Urologia 1: A. Gregori; Gela, Ospedale Vittorio Emanuele: N. Condorelli; Genova, Clinica Urologica dell'Azienda Ospedaliero Universitaria San Martino: C. Terrone; Genova, Ente Ospedaliero - Ospedali Galliera: C. Introini; Gravina di Catania, Casa di Cura Musumeci Gecas: R. Leonardi; Guastalla, Ospedale Civile: A. Frattini; Isola della Scala, Ospedale Civile: G. Pecoraro; Jesi, Ospedale Carlo Urbani: V. Ferrara; L’Aquila, Ospedale S. Salvatore: L. Di Clemente; Lanciano, Ospedale Floraspe Renzetti: L. Schips; Latina, Ospedale ICOT: A. Carbone; Lecce, ASL Vito Fazzi: A. Filoni Lido di Camaiore, Ospedale Versilia-USL 12 Toscana Nord Ovest: M Cecchi; Mirone_Stesura Seveso 03/01/18 12:12 Pagina 257 Archivio Italiano di Urologia e Andrologia 2017; 89, 4 V. Mirone, G. Carrieri, G. Morgia, L. Carmignani, G. Vespasiani, F. Parazzini, W. Artibani 258 Locri Ospedale Spoke: A. Verbena; Lovere Ospedale SS Capitanio e Gerosa: A Ranieri; Lucca, Nuovo ospedale San Luca - USL Nord-Ovest: G. Santelli; Magenta, Ospedale Civile: S. Sandri; Mantova, Ospedale Poma: B. Dall’Oglio; Messina, Azienda Ospedaliera Universitaria Policlinico G. Martino: V. Ficarra; Messina, Casa di Cura S. Camillo: S. Bruschetta; Messina, Ospedali Riuniti Papardo Piemonte: F. Mastroeni; Milano, Azienda Socio Sanitaria Santi Paolo e Carlo: G. Dormia; Milano, ASST Grande Ospedale Metropolitano Niguarda: A. Bocciardi; Milano, Fondazione Ca' Granda - I.R.C.C.S. - Ospedale Maggiore - Policlinico: E. Montanari; Milano, Humanitas-San Pio X: L. Nava; Milano, Istituto Europeo di Oncologia: O. De Cobelli; Milano, Ospedale S. Raffaele: F. Montorsi; Mirabella Eclano, Casa di Cura Villa Maria: E. Morelli; Modena, Hesperia Hospital: G. Ferrari; Modena, OCSAE - Nuovo Ospedale Civile Sant'Agostino Estense: G. Bianchi; Molfetta, Ospedale Don Tonino Bello: M. Altomare; Mondragone, Clinica Padre Pio: G.S. Sepe; Monopoli, Ospedale Civile S. Giacomo: V. Recapito; Montepulciano, Stabilimento Ospedaliero Nottola: G. Oliva; Napoli, Azienda Ospedaliera Universitaria - Seconda Università degli Studi: M. De Sio; Napoli, Istituto Nazionale Tumori IRCCS Fondazione Pascale: S. Perdonà; Napoli, Ospedale Buon Consiglio Fatebenefratelli: V. Imperatore; Napoli, Ospedale Cardarelli: P. Fedelini; Napoli, Ospedale Cardinale Ascalesi: A.R. Zito; Napoli, Ospedale Vincenzo Monaldi: F. Uricchio; Napoli, Policlinico Federico II: V.G. Mirone; Negrar, Ospedale Sacro Cuore: S. Cavalleri; Nocera Inferiore, P:O: Umberto I: R. Sanseverino; Novara, Azienda Ospedaliero Universitaria Maggiore della Carità : A. Volpe; Novi Ligure, Ospedale San Giacomo - ASL 22: F. Montefiore; Nuoro, Ospedale San Francesco: F.M. Cossu; Orbassano, Azienda Ospedaliero-Universitaria S. Luigi Gonzaga: F. Porpiglia; Ottaviano, Casa di Cura Trusso: G. De Stefano; Padova, Azienda Ospedaliera: F. Zattoni; Padova, Centro Poliambulatorio ai Colli: M. Dal Bianco; Palermo, Azienda Universitaria Ospedaliera Policlinico Paolo Giaccone: A. Simonato; Parma, AOU: U.V. Maestroni; Perugia, Ospedale S. Maria della Misericordia - S. Andrea delle Fratte: E. Mearini; Pescara, Clinica Pierangeli: P. Pompa; Pescara, Presidio Ospedaliero: R. Renzetti; Peschiera del Garda, Casa di Cura Pederzoli: G. Grosso; Piacenza, Ospedale Guglielmo da Saliceto: I.M. Tavolini; Pisa, Azienda Ospedaliero Universitaria Pisana - Stabilimento di Cisanello: C. Selli; Polla, Presidio Ospedaliero di Polla-ASL Salerno: D. Rubino; Ponderano, Ospedale degli Infermi - ASL Biella: S. Zaramella; Pordenone, AIED: S. Bucci; Pozzuoli, Ospedale Santa Maria delle Grazie: G. Di Lauro; Prato, Ospedale Misericordia e Dolce: F. Blefari; Ragusa, Ospedale Civile, F. Curto; Ravenna, Ospedale S. Maria delle Croci: S. Voce; Reggio Calabria, ASL 11 Struttura Nord: M. De Martin; Rimini, Ospedale degli Infermi: F. Montanari; Rocca di Neto: F. Greco; Roma, Aurelia Hospital: R. Cusumano; Roma, Azienda ospedaliera Sant’Andrea: A. Tubaro; Roma, Casa di Cura Nuova Villa Claudia: R. Giulianelli; Roma, Clinica Fabia Mater: M. Cappa; Roma, Complesso Integrato Columbus: A. D’Addessi; Roma, Fondazione PTV Policlinico - Tor Vergata: G. Vespasiani; Roma, Ospedale di Zona Cristo Re: L. Defidio Roma, Ospedale S. Carlo Forlanini: C. Anceschi; Roma, Ospedale S. Filippo Neri: G. Sampalmieri; Roma, Policlinico A. Gemelli: P. Bassi; Roma, Policlinico Umberto I: C. De Dominicis; Roma, Policlinico Universitario Campus Bio-Medico: G. Muto; Salerno, AOU S. Giovanni di Dio R. d’Aragona: U. Greco; San Bonifacio; Ospedale Fracastoro: C.Tallarigo; San Cataldo, Casa di Cura Regina Pacis:C. Cammarata; San Donà di Piave, Casa di Cura Sileno ed Anna Rizzola: G. Loiero; San Donato Milanese, Ospedale Clinicizzato S. Donato: L.F. Carmignani; San Giovanni Rotondo, Ospedale Casa Sollievo della Sofferenza: A. Cisternino; Santa Maria Capua Vetere, Clinica S. Maria della Salute: M. Sorrentino; Sarzana, Ospedale San Bartolomeo: E. Conti; Sassari, Azienda Ospedaliero-Universitaria: M. Madonia; Senigallia, Ospedale Principe di Piemonte: A. Cavicchi; Sestri Levante, ASL4- Chiavarese: M. Medica; Siena,AOUS Ospedale S. Maria delle Scotte: G. Barbanti; Siracusa, Azienda Ospedaliera Umberto I: B. Lentini; Sondrio, Ospedale di Sondrio - Azienda Ospedaliera di Valtellina e Valchiavenna: P. Piras; Taranto Ospedale Ss Annunziata: F Beleggia; Teramo, Ospedale Mazzini: C. Vicentini; Termoli, Ospedale San Timoteo: G. Di Monaco; Terni, Azienda Ospedaliera Santa Maria: E. Mearini; Tivoli, Ospedale S. Giovanni Evangelista: A. Laganà: Trento, Ospedale Santa Chiara: G. Malossini; Treviglio, Ospedale di Treviglio-Caravaggio-ASST BG Ovest: O. Risi; Torino, Città della Salute e della Scienza-Ospedale Molinette: P. Gontero; Torino, Ospedale Cottolengo: C.M. Scoffone; Torino, Ospedale San Giovanni Bosco Castelli di Torino - SC Urologia 2: E. Castelli; Torino, Presidio Ospedaliero CTO - Unità Spinale Struttura Complessa di Neuro Urologia: R. Carone; Udine, AIED: S. Ciciliato; Vallo della Lucania, Casa di Cura Luigi Cobellis: A. Cavaliere; Varese, Ospedale di Circolo Fondazione Macchi: A.M. Marconi; Vasto, Ospedale San Pio da Pietrelcina: L.Schips; Vercelli, Ospedale S. Andrea: G. Cipollone; Verona, Azienda Ospedaliera-Universitaria Integrata - Ospedale Borgo Trento: W. Artibani; Viterbo, Ospedale di Belcolle: A. Rizzotto; Voghera, Azienda Socio Sanitaria Territoriale di Pavia - Ospedale Civile: M. Mensi. 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