Stesura Seveso 245Archivio Italiano di Urologia e Andrologia 2019; 91, 4 ORIGINAL PAPER Effect of body mass and physical activity at younger age on the risk of prostatic enlargement and erectile dysfunction: Results from the 2018 #Controllati survey Fabio Parazzini 1, Walter Artibani 2, Giuseppe Carrieri 3, Luca Carmignani 4, Salvatore Voce 5 on behalf of the #Controllati study group* 1 Università degli Studi di Milano Dipartimento di Scienze Cliniche e di Comunità, IRCCS Policlinico, Milano, Italy; 2 Società Italiana di Urologia (SIU), Roma, Italy; 3 Dipartimento Nefro/Urologico Clinica Urologica e Centro Trapianti di Rene, Università degli Studi di Foggia, Italy; 4 Università degli Studi di Milano, Unità Operativa Complessa, Ospedale Policlinico San Donato, Milano, Italy; 5 Divisione di Urologia Ospedale Santa Maria delle Croci, Ravenna, Italy. Objective: Overweight and low physical activity (PA) increase the risk of prostatic enlargement and erectile dysfunction (ED). Less clear is the role of these factors at young age on the lifelong risk. Materials and methods: During June 2018 the Italian Society of Urologists organized the month of Male Urologic Prevention “#Controllati”. Men aged 18 years or more were invited to attend urologic centers for a visit and counselling about uro- logic/andrologic conditions. Each participating man underwent a physical examination and was asked about urologic symp- toms, sexual activity and possible related problems. Results: We analyzed data from 2786 men, aged 55.1 years (SD 10.9, range 19-97). A total of 710 (25.5%) subjects had a diagnosis of prostatic enlargement and 632 (22.7%) of DE. Overweight/obese men were at increased risk of prostatic enlargement and ED with corresponding odds ratio (0R) in comparison with normal or underweight men, being respec- tively 1.18 (95% Confidence Interval (CI) 1.00-1.44) and 1.69 (95% CI 1.39-2.05). The OR of prostatic enlargement in com- parison with men reporting at age 25 a BMI < 25.0 was 1.22 (95% CI 1.01-1.51) for men with a BMI at 25 years of age ≥ 25; the corresponding OR value for ED was 1.17 (0.92- 1.48). Considering total PA at diagnosis, the OR of prostatic enlargement in comparison with no or low PA, was 0.69 (95%CI 0.55-0.86) for men reporting moderate PA and 0.75 (95%CI 0.58-0.98) for those reporting intense PA. When we considered PA at 25 years of age, the OR of subsequent diag- nosis of prostatic enlargement, in comparison with men report- ing no/low PA at 25 years of age was 0.81 (95%CI 0.63-1.04) for men reporting moderate PA and 0.70 (95%CI 0.52-0.99) for those reporting intense PA. Conclusions: These findings underline the utility of encourag- ing healthy lifestyle habits among young men in order to reduce the subsequent risk of prostatic enlargement and ED. KEY WORDS: Benign prostatic enlargement; Hypertension; Diabetes; Heart disease; Body mass index; Physical activity. Submitted 10 April 2019; Accepted 1 May 2019 Summary No conflict of interest declared. DOI: 10.4081/aiua.2019.4.245 INTRODUCTION Benign prostatic enlargement (BPE) and erectile dysfunction (ED) are the two most common urologic diseases in men, the estimated prevalence of PE being about 10% in the fourth decades increasing up to 50% thereafter and that of ED being 12% (1, 2). Among the risk factors for these two conditions, lifestyles play a major role. It is well recognized, for example, that overweight, low physical activity (PA), hypertension, hypercholesterolemia and hypertriglyceridemia increase the risk of these condi- tions at advanced age (3-6). Less clear is the role of these factors on the lifelong risk when they were present at younger age (7). Since 2016 the Italian Urologic Society (SIU, Società Italiana di Urologia) coordinates a huge preventive initiative: the month of Male Urologic Prevention ”#Controllati” (8, 9). In the framework of this preventive campaign data have been collected on determinants of the risk of prostatic enlargement and ED. In this paper we present the results of the 2018 initiative with a special focus on risk factors for prostatic enlarge- ment and ED and on lifelong risk for these condition in relation to lifestyle at younger age. METHODS During June 2018, men aged 18 year or more were invit- ed to attend the participating urologic centers for a free of charge visit and counselling about urologic or andro- logic conditions. A pamphlet inviting men for check-up was distributed in chemists and general practitioners’ waiting rooms. An advertising campaign was also set on media. At visit, general data were recorded using a simple ques- tionnaire. The first section of the questionnaire, includ- ing data on age, life habits height and weight, was com- pleted by the patient. The section on PA included ques- tions on self-reported intensity of PA (‘none’, ‘low’, ‘moderate’,‘intense’) at work and in leisure time sepa- rately. History of hypertension, diabetes, cardiopathy, hypertriglyceridemia and hypercholesterolemia were checked by the urologist. Information was also collected on body mass index (BMI) and total PA at age 25 year among men aged 30 year or more. Parazzini_Stesura Seveso 14/01/20 12:44 Pagina 245 Archivio Italiano di Urologia e Andrologia 2019; 91, 4 F. Parazzini, W. Artibani, G. Carrieri, L. Carmignani, S. Voce on behalf of the #Controllati study group 246 Each participating man underwent a physical examina- tion, including digital rectal examination (DRE), and was asked by the urologist about urologic symptoms, sexual activity and possible related problems. Diagnosis of pro- static enlargement was made by the urologist by DRE. Erectile function was assessed by asking men about their sexual performance: ED was diagnosed, according to the definition of the NIH Consensus Development Panel (10), when a man was consistently unable to attain or main- tain a penile erection sufficient for satisfactory sexual performance. The 2002 ICS definitions were used for frequency, nic- turia, urgency, dysuria (intermittency, slow stream, straining, terminal dribble, postmicturition dribble) incomplete emptying (11). A man was considered a smoker if he had smoked more than one cigarette/day for at least one year; ex-smoker if he had smoked more than one cigarette/day for at least one year, but had stopped more than one year before the interview, and non-smoker if he had never smoked more than one cigarette/day. Total PA was evaluated combining occupational and leisure time PA. Frequencies (%) were computed as appropriate. Odds ratios (OR), and the corresponding 95% confidence intervals (CI), adjusted for age were derived using unconditional multiple logistic regression, fitted by the method of maximum likelihood, in which the depend- ent variable was the presence (case) or absence (control) of the condition and the independent ones were the expo- sures considered in the analysis. We included in the model age considered as categorical variable (12). RESULTS During the 2018 campaign a total of 3092 men entered the study. After exclusion of men who underwent previ- ous surgery for partial or complete prostatectomy and those who did not answer at least one of two questions about PA, we analyzed data from 2786 men, aged 55.1 years (SD 10.9, range 19-97). The reason for visit was urinary symptoms in 504 (18.1%), sexual problems in 270 (9.7%), renal disease in 68 (2.4%) and prostatic problems in 429 (15.4%) (more than one reason was allowed). Prevention was the only reason for consulta- tion in 1776 subjects (63.8%). A total of 710 (25.5%) subjects had a diagnosis of prostatic enlargement and 632 (22.7%) of DE. Table 1 shows the distribution, and the corresponding OR, of study subjects according to the diagnosis of prostatic enlargement, ED and age, smoking habits and BMI. The risk of prostatic enlargement and ED increased with age: in comparison with men aged <=40 years or less, the risk of prostatic enlargement was 2.57, 7.22, 17.97 and 39.1 in the age classes 41-50, 51-60, 61-70 and >=71, respectively. The corresponding values for ED were 1.15, 1.63, 3.06 and 4.87. Smoking increased the risk of ED: in comparison with never smokers, ex-smokers had an increased risk of ED of 1.38 (95%CI 1.11-1.69) and current smokers of 1.92 (95%CI 1.49-2.48). Overweight/obese men were at increased risk of prostatic enlargement and ED the corresponding 0R, in comparison with normal or underweight men, being respectively 1.18 (95%CI 1.00-1.44) and 1.69 (95%CI 1.39-2.05). We have also considered (among men aged 30 years or more) the role of overweight/obesity at 25 years of age on the subsequent risk of prostatic enlargement and ED. In comparison with men reporting at age 25 a BMI < 25.0, the OR of prostatic enlargement was for men with a BMI at 25 years of age ≥ 25, 1.22 (95%CI 1.01-1.51); the corresponding value for ED was 1.17 (95%CI 0.92- 1.48). Table 2 considers the relation between prostatic enlarge- ment and DE and urinary symptoms, hypertension, dia- betes, cardiopathy, hypertriglyceridemia and hypercho- lesterolemia. Table 1. Odds ratios (and corresponding 95% confidence intervals) of BPE and erectile dysfunction according to selected factors. Benign prostatic enlargement Age adj OR (95%CI) Erectile dysfunction Age adj OR (95%CI) No Yes No Yes No.* (%) No.* (%) No.* (%) No.* (%) Age (years) ≤ 40 166 7.8 7 0.9 1° 150 6.8 23 3.5 1° 41-50 782 36.8 87 11.5 2.57 (1.17-5.66) 736 33.2 133 20.0 1.15 (0.71-1.85) 51-60 718 33.8 225 29.6 7.22 (3.34-15.63) 752 33.9 191 28.7 1.63 (1.02-2.60) 61-70 339 16.0 269 35.4 17.97 (8.29-38.96) 413 18.6 195 29.3 3.06 (1.91-4.90) ≥ 71 118 5.6 171 22.5 35.10 (15.83-77.86) 165 7.4 124 18.6 4.87 (2.94-8.06) Smoking habits Never 1131 53.3 342 45.1 1° 1198 54.1 275 41.3 1° Ex smokers 624 29.4 303 39.9 1.2 (0.98-1.47) 668 30.1 259 38.9 1.38 (1.12-1.69) Current smokers 343 16.2 103 13.6 1.1 (0.84-1.47) 317 14.3 129 19.4 1.92 (1.49-2.48) < 10 cig/day 127 8.5 34 7.5 0.94 (0.58-1.53) 130 8.5 31 7.6 1.49 (0.96-2.29) ≥ 10 cig/day 192 12.9 67 14.8 1.27 (0.90-1.78) 174 11.3 85 21.0 2.25 (1.66-3.06) BMI (kg/m2) < 25.0 891 43.2 253 35.8 1° 949 44.1 195 30.8 1° ≥ 25.0 1172 56.8 453 64.2 118. (1.00-1.44) 1189 55.2 436 69.0 1.69 (1.39-2.05) BMI at 25 years of age < 25.0 1293 62.3 443 62.4 1° 1335 62.0 401 63.4 1° ≥ 25.0 384 18.5 123 17.3 1.22 (1.01-1.51) 381 17.7 126 19.9 1.17 (0.92-1.48) *Sometimes, the sums do not add up the total due to missing values; °reference category OR: odds ratio; CI: confidence interval. Parazzini_Stesura Seveso 14/01/20 12:44 Pagina 246 A history of hypertension, diabetes, cardiopathy, high cholesterol levels were significantly associated to an increased risk of prostatic enlargement in the total series. Likewise, hypertension, diabetes, cardiopathy, high triglyceride and cholesterol levels were significantly asso- ciated to an increased risk of ED. 247Archivio Italiano di Urologia e Andrologia 2019; 91, 4 Lifestyle habits and prostatic enlargement Table 2. Odds ratios (and corresponding 95% confidence intervals) of BPE and erectile dysfunction according to medical history. Benign prostatic enlargement adj OR (95%CI) Erectile dysfunction adj OR (95%CI) No Yes No Yes No.* (%) No.* (%) No.* (%) No.* (%) Urinary symptoms** No 987 46.5 101 13.3 1° 924 41.7 164 24.6 1° Yes 1136 53.5 658 86.7 5.14 (3.97-6.67) 1292 58.3 502 75.4 1.82 (1.47-2.25) Erectile dysfunction No 1698 80.0 518 68.2 1° - - - - - Yes 425 20.0 241 31.8 1.27 (1.03-1.57) - - - - - Benign prostatic enlargement No - - - - - 1698 76.6 425 63.8 1° Yes - - - - - 518 23.4 241 36.2 1.27 (1.03-1.57) Hypertension No 1492 70.3 369 48.6 1° 1524 68.8 337 50.6 1° Yes 407 19.2 275 36.2 1.6 (1.30-2.619) 457 20.6 225 33.8 1.60 (1.29-1.99) Missing 224 10.6 115 15.2 235 10.6 104 15.6 -- Diabetes No 1884 88.7 599 78.9 1° 1964 88.6 519 77.9 1° Yes 78 3.7 80 10.5 1.57 (1.08-1.85) 82 3.7 76 11.4 2.43 (1.70-3.47) Missing 161 7.6 80 10.5 170 7.7 71 10.7 - Cardiopathy No 1857 87.5 577 76.0 1° 1925 86.9 509 76.4 1° Yes 76 3.6 74 9.7 1.30 (1.02-1.67) 80 3.6 70 10.5 2.12 (1.47-3.06) Missing 190 8.9 108 14.2 211 9.5 87 13.1 - Hypertriglyceridemia No 1753 82.6 586 77.2 1° 1830 82.6 509 76.4 1° Yes 130 6.1 62 8.2 1.31 (0.92-1.85) 130 5.9 62 9.3 1.59 (1.13-2.22) Missing 240 11.3 111 14.6 256 11.6 95 14.3 - Hypercholesterolemia No 1548 72.9 492 64.8 1° 1613 72.8 427 64.1 1° Yes 301 14.2 143 18.8 1.30 (1.02-1.67) 315 14.2 129 19.4 1.42 (1.11-1.81) Missing 274 12.9 124 16.3 288 13.0 110 16.5 - *Sometimes, the sums do not add up the total due to missing values; **one or more of the followings: nocturia, urgency, dysuria (intermittency, slow stream, straining, terminal dribble, postmicturition dribble) incomplete emptying; °reference category; adjOR: adjusted odds ratio; CI: confidence interval. Table 3. Odds ratios (and corresponding 95% confidence intervals) of premature ejaculation and erectile dysfunction according to physical activity. Benign prostatic enlargement adj OR (95%CI) Erectile dysfunction adj OR (95%CI) No Yes No Yes No.* (%) No.* (%) No.* (%) No.* (%) Occupational PA None/Low 1002 48.3 354 49.9 1° 1035 48.1 321 50.8 1° Moderate 631 30.4 198 27.9 0.89 (0,7-1,1) 657 30.5 172 27.2 0.86 (0.69-1.08) Intense 283 13.6 80 11.3 0.97 (0.72-1.31) 286 13.3 77 12.2 0.98 (0.73-1.30) Missing 160 7.7 78 11.0 176 8.2 62 9.8 - Leisure PA Low 767 36.9 317 44.6 1° 785 36.4 299 47.3 1° Moderate 893 43.0 272 38.3 0.67 (0.55-0.83) 926 43.0 239 37.8 0.66 (0.54-0.80) Intense 319 15.4 84 11.8 0.64 (0.51-0.91) 342 15.9 61 9.7 0.48 (0.36-0.66) Missing 97 4.7 37 5.2 101 4.7 33 5.2 - Total PA Low 537 25.9 228 32.1 1° 544 25.3 221 35.0 1° Moderate 960 46.2 308 43.4 0.69 (0.55-0.86) 995 46.2 273 43.2 0.65 (0.53-0.80) Intense 515 24.8 144 20.3 0.75 (0.58-0.98) 545 25.3 114 18.0 0.56 (0.43-0.72) Missing 64 3.1 30 4.2 70 3.2 24 3.8 - PA at 25 years of age Low 401 19.3 160 22.5 1° 415 19.3 146 23.1 1° Moderate 820 39.5 273 38.5 0.81 (0.63-1.04) 858 39.8 235 37.2 0.78 (0.61-0.99) Intense 773 37.2 244 34.4 0.70 (0.52-0.99) 785 36.4 232 36.7 0.74 (0.58-1.10) Missing 82 3.9 33 4.6 96 4.5 19 3.0 - *Sometimes, the sums do not add up the total due to missing values; °reference category; adjOR: adjusted odds ratio; CI: confidence interval. Parazzini_Stesura Seveso 14/01/20 12:44 Pagina 247 Archivio Italiano di Urologia e Andrologia 2019; 91, 4 F. Parazzini, W. Artibani, G. Carrieri, L. Carmignani, S. Voce on behalf of the #Controllati study group 248 PA was significantly associated with a decreased risk of prostatic enlargement: considering the total PA at diag- nosis, the OR of prostatic enlargement, in comparison with men reporting no or low PA, was 0.69 (95%CI 0.55-0.86) among men reporting moderate PA and 0.75 (95%CI 0.58-0.98) among those reporting intense PA. The OR of subsequent diagnosis of prostatic enlargement were, in comparison with men reporting no/low PA at 25 years of age 0.81 (95%CI 0.63-1.04) for men reporting moderate PA and 0.70 (95%CI 0.52-0.99) for those reporting intense PA at 25 years of age. Similar findings emerged when we considered ED risk. DISCUSSION The general results of this analysis show that low PA, high BMI and a history of hypertension, diabetes, hyper- cholesterolemia, cardiopathy increase the risk of prosta- tic enlargement. High BMI and low PA at 25 year of age increase the risk of prostatic enlargement at older ages. Similar results emerged also for the risk profile of ED. Limitations As already discussed in the papers presenting the results of 2016 and 2017 initiative (8, 9), the major flaw of this study is that the study population were men voluntarily presenting to the participating centers. The participating centers were not randomly identified among all Italian urologic centers, so they cannot be considered represen- tative of all Italian centers. However, they were well dis- tributed over the main areas of the country. 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 PE was based on DRE that tends to underestimate the prostatic volume (2). Any misclassifi- cation of men with or without BPE or should lower the observed associations. With regard to the diagnosis of DE, it was reported by the men and checked for standard criteria by the physician. The results of this study confirm data from different pop- ulations that have reported that high BMI, low PA and a history of hypertension, diabetes, hypercholesterolemia, increase the risk of BPE at all ages (13, 14). All these findings underline that benign BPE shares similar risk factors with metabolic syndrome and cardiovascular dis- eases. The etiological mechanisms that links these risk factors and prostatic growth are not completely understood. However, it has been shown that lipids (oxidized low- density lipoproteins) increase in vitro the secretion of growth and pro-inflammatory factors by human stromal BPE cells in culture (15). Along this line, in a clinical per- spective, the addition of statins to standard therapy for benign PE lowered prostate volume (16). Further, alter- ation of sex steroid hormone metabolism caused by both obesity and diabetes could lead to ‘pro-inflammatory’ conditions, causing release of chemokines potentially associated with prostate enlargement (17). Regular PA has been consistently reported to decrease the risk of BPE. A meta-analysis has shown that moder- ate-to-vigorous physical activity was associated with up to a 25% decreased risk of benign prostatic enlargment, with the magnitude of the protective effect increasing with the higher levels of activity (18). An interesting finding from the present study is the obser- vation that the OR of BPE and ED associated with none/low PA and high BMI at 25 years were higher than unity. Few data have been published on the role of PA at younger ages on the lifetime risk of BPE. A previous Italian case control study have reported that moderate/intense recreational physical activity (> 2 hours week) at age 30-39 decrease the risk of benign BPE of about 30%. The Authors concluded that avoidance of sedentary lifestyle through a moderate recreational PA at any age may help preventing a sizeable number (e.g., approximately 20%) of BPE cases (7). With regard to erectile dysfunction, the risk profile of ED was largely similar with that observed for prostatic enlarge- ment. In particular, the present analysis confirms that smoking, overweight, low PA and history of diabetes, hypertension, cardiopathy, hypercholesterolemia, hyper- triglyceridemia, all increased the risk of ED. All these findings underline the role of encouraging healthy lifestyle habits among young men in order to reduce the subsequent risk of prostatic enlargement and ED. REFERENCES 1. Parazzini F, Menchini Fabris F, Bortolotti A, et al, Frequency and determinants of erectile dysfunction in Italy. 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Città della Salute e della Scienza - Ospedale Molinette, Torino (Gontero Paolo) Arcispedale Sant'Anna Ferrara (Ippolito Carmelo) ASL Reggio Calabria (De Martin Michele) P.O. Umberto I, Nocera Inferiore (Sanseverino Roberto) ASL Presidio Ospedaliero Carmagnola, Chieri (Marino Gaetano) ASST Franciacorta - Ospedale M. Mellini (Chiari Tralce Luigi) Ospedale Mater Salutis Legnago (Curti Pierpaolo) Aurelia Hospital, Roma (Cusumano Roberto) Azienda Ospedaliera Universitaria di Sassari (Madonia Massimo) Azienda Ospedaliera "Umberto I" Siracusa (Lentini Bartolomeo) Azienda Ospedaliera Universitaria, Parma (Maestroni Umberto Vittorio) Azienda Ospedaliera, Padova (Zattoni Filiberto) Azienda Ospedaliera Gaetano Rummo Benevento (Salzano Luigi) Azienda Ospedaliera Ospedali Riuniti Papardo Piemonte, Messina (Mastroeni Francesco) Azienda Ospedaliera Policlinico di Bari (Ditonno Pasquale) Azienda Ospedaliera Policlinico di Bari (Battaglia Michele) Azienda Ospedaliera Pugliese Ciaccio Catanzaro (Pirritano Domenico) Azienda Ospedaliera S. Antonio e Biagio, Alessandria (Serao Armando) Azienda Ospedaliera S. Bortolo, Vicenza (Ferrarese Paolo) Azienda Ospedaliera S. Giuseppe Moscati, Avellino (Cicalese Virgilio) Azienda Ospedaliera Sant’Anna e San Sebastiano di Caserta (Caggiano Sergio) Azienda Ospedaliera Santa Maria Terni (Elisabetta Costantini) Azienda Ospedaliera-Universitaria - "L. Vanvitelli" Napoli (De Sio Marco) Azienda Ospedaliera-Universitaria Integrata Verona (Artibani Walter) Azienda Ospedaliera-Universitaria Mater Domini di Catanzaro (Damiano Rocco) Azienda Ospedaliera-Universitaria Policlinico G. Martino Messina (Ficarra Vincenzo) Azienda Ospedaliero-Universitaria "Policlinico - Vittorio Emanuele" Catania (Falsaperla Mari) Azienda Ospedaliero-Universitaria Careggi, Firenze (Carini Marco) Azienda Ospedaliero-Universitaria S. Luigi Gonzaga Orbassano (Porpiglia Francesco) Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara (Volpe Alessandro) Azienda Ospedaliero-Universitaria Pisana - Stabilimento di Cisanello (Selli Cesare) Azienda Ospedaliero-Universitaria Sant' Andrea, Roma (Tubaro Andrea) Ospedale Civile di Voghera (Mensi Mario) Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo, Milano (Dormia Guido) Campus Università degli Studi "Gabriele d'Annunzio" Chieti (Raffaele Tenaglia) Casa di Cura Ambrosiana Cesano Boscone (Catanzaro Francesco) Casa di Cura Gibiino Catania (Ranno Christian) Casa di Cura Giovanni XXIII, Monastier di Treviso (Morana Carmelo) Casa di Cura Guarnieri, Roma (Di Marco Massimiliano) Casa di Cura Luigi Cobellis Vallo della Lucania (Cavaliere Aniello) Casa di Cura Malatesta Novello Cesena (Cuzzocrea Diego) Casa di Cura Musumeci Gecas Gravina di Catania (Leonardi Rosario) Casa di Cura Nuova Clinica Santa Rita Benevento (Coscione Mario) Casa di Cura Nuova Villa Claudia, Roma (Giulianelli Roberto) Casa di Cura Regina Pacis, San Cataldo (Cammarata Carla) Casa di Cura Romolo Hospital Rocca di Neto (Cappa Manlio) Casa di Cura S. Rita, Atripalda De Simone Elia Virginio; Casa di Cura San Camillo Messina (Bruschetta Sebastiano); Casa di Cura Santa Lucia San Giuseppe Vesuviano (Casoli Eugenio) Casa di Cura Sileno ed Anna Rizzola, San Donà di Piave (Loiero Gaetano) Casa di Cura Trusso, Ottaviano (De Stefano Giacomo) Casa Di Cura Villa Betania, Roma (Buscarini Maurizio) Casa di Cura Villa dei Fiori, Mugnano di Napoli (Jungano Renato) Casa di Cura Villa Esther, Avellino (Di Martino Mario) Casa di Cura Villa Fiorita, Prato (Dami Andrea Cesare) Casa di Cura Villa Igea, Ancona (Cafarelli Angelo) Casa di Cura Villa Maria, Mirabella Eclano (Morelli Emilio) Casa di Cura Villa Stabia Castellammare di Stabia (Scognamiglio Giuseppe) Centro Medico Politerapica, Seriate (Paolo Belvisi) Clinica Athena Villa dei Pini, Piedimonte Matese (Dalena Giuseppe) Clinica Padre Pio, Mondragone (Sepe Giuseppe Salvatore) Clinica Pierangeli, Pescara (Pompa Paolo) Clinica Villa Pia, Roma (Campagna Adriano) Casa di Cura Pederzoli, Peschiera del Garda (Grosso Gaetano) Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti (Ludovico Giuseppe Mario) Ospedale Galliera, Genova (Introini Carlo); Fondazione Policlinico IRCCS, Milano (Montanari Emanuele); Fondazione PTV Policlinico, Tor Vergata, Roma (Vespasiani Giuseppe); Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria (Cozzupoli Pietro); Hesperia Hospital, Modena (Ferrari Giovanni); Humanitas Gradenigo, Torino (Muto Giovanni); Humanitas San Pio X, Milano (Nava Luciano); IRCCS Policlinico San Donato (Carmignani Luca); IRCCS Policlinico Milano (Elena Ricci, data analysis); IRCCS AOU San Martino IST, Genova (Terrone Carlo); Istituti Clinici Zucchi, Monza (Stefano Casellato); Istituto Clinico S. Anna, Brescia (Najati Alrabi); Istituto Europeo di Oncologia, Milano (De Cobelli Ottavio); Istituto Nazionale Tumori IRCCS "Fondazione Pascale" Napoli (Perdonà Sisto); Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo (Cisternino Antonio); Ospedale Buon Consiglio Fatebenefratelli, Napoli (Imperatore Vittorio); Ospedale Cardarelli, Napoli (Fedelini Paolo); Ospedale Carlo Urbani, Jesi (Ferrara Vincenzo); Ospedale Civico di Cristina Benfratelli , Palermo (Gianfranco Savoca); Ospedale Civile di Guastalla (Frattini Antonio); Ospedale Civile P.O. Dell'Annunziata, Cosenza (Emilio De Giacomo); Ospedale Civile Ramazzini Carpi (Barusi Maurizio); Ospedale Civile S. Giacomo, Monopoli (Vito Domenico Ricapito); Ospedale Civile San Salvatore, L’Aquila (Di Clemente Luigi); Ospedale Cottolengo, Torino (Scoffone Cesare Marco); Ospedale degli Infermi, Rimini (Montanari Francesco); Ospedale del Mare, Napoli (Zito Aniello Rosario) ; Ospedale della Murgia Fabio Perinei, Altamura (De Siati Mario); Ospedale di Bassano del Grappa (Celia Antonio); Ospedale di Belcolle, Viterbo (Rizzotto Antonio); Ospedale di Senigallia (Vincenzo Ferrara); Ospedale di Sondrio (Giumelli Pierluigi); Ospedale di Villafranca di Verona (Pecoraro Giuseppe); Ospedale Cristo Re, Roma (Lorenzo Defidio); Ospedale Don Tonino Bello Molfetta (Altomare Mauro); Ospedale Garibaldi Nesima, Catania (La Rosa Pasquale Gianfranco); Ospedale ICOT, Latina (Carbone Antonio); Ospedale L. Bonomo, Andria (Corvasce Antonio); Ospedale Madonna delle Grazie, Matera (Disabato Giuseppe); Ospedale Maggiore, Bologna (Emili Emilio); Parazzini_Stesura Seveso 14/01/20 12:44 Pagina 249 Archivio Italiano di Urologia e Andrologia 2019; 91, 4 F. Parazzini, W. Artibani, G. Carrieri, L. Carmignani, S. Voce on behalf of the #Controllati study group 250 Ospedale Maria SS. Addolorata, Erboli (Tufano Antonio); Ospedale Niguarda Ca' Granda, Milano (Bocciardi Aldo); Ospedale Privato Accreditato Villa Regina, Bologna (Cuzzocrea Diego Ettore); Ospedale Villa Serena, Forlì (Zambelli Massimo); Ospedale S. Giacomo di Novi Ligure (Montefiore Franco); Ospedale S. Giovanni in Persiceto (Emilo Emili); Ospedale S. Maria della Misericordia, S. Andrea delle Fratte Perugia (Ettore Mearini); Ospedale S. Maria delle Croci, Ravenna (Voce Salvatore); Ospedale S. Raffaele Turro, Milano (Gaboardi Franco); Ospedale Sacro Cuore di Gesù Fatebenefratelli, Benevento (Ferravante Paolo); Ospedale Sacro Cuore Don Calabria, Negrar (Cavalleri Stefano); Ospedale San Bartolomeo, Sarzana (Conti Enrico); Ospedale San Biagio DomodossolaRosa Antonio; Ospedale San Camillo Forlanini, Roma (Gaffi Marco); Ospedale San Donato, Arezzo (De Angelis Michele); Ospedale San Giacomo Apostolo, Castelfranco Veneto (Luca De Zorzi); Ospedale San Giovanni Battista, Foligno (Mearini Luigi); Ospedale San Giovanni di Dio, Agrigento (Ruoppolo Michele); Ospedale San Pio da Pietrelcina, Vasto (Schips Luigi); Ospedale San Raffaele, Milano (Montorsi Francesco); Ospedale San Salvatore. Pesaro (Beatrici Valerio); Ospedale San Tommaso dei Battuti, Portogruaro (Amenta Michele); Ospedale Sant'Ottone Frangipane, Ariano Irpino (Grasso Gerardo); Ospedale Santa Maria Misericordia, Udine (Valotto Claudio); Ospedale Santa Maria Regina degli Angeli, Adria (Meneghini Agostino); Ospedale Santissima Trinità, Cagliari (De Lisa Antonello); Ospedale Spoke, Locri (Capocasale Francesco); Ospedale SS. Capitanio e Gerosa, Lovere (Ranieri Antonio); Ospedale Vincenzo Monaldi, Napoli (Uricchio Francesco); Ospedali Riuniti di Ancona (Galosi Andrea Benedetto); Ospedali Riuniti di Foggia (Carrieri Giuseppe), Presidio Ospedaliero Cerignola (Annunziata Gennaro); P.O. S. Marta e S. Venera di Acireale (Ingrassia Antonino); P.O. Umberto I, Enna (D'Anca Michele); Policlinico Agostino Gemelli, Roma (Bassi Pierfrancesco); Policlinico di Abano Terme (Porreca Angelo); Ospedale Civile di Baggiovara (Bianchi Giampaolo); Policlinico Federico II, Napoli (Mirone Vincenzo); Policlinico S. Orsola-Malpighi, Bologna (Brunocilla Eugenio); Policlinico SS. Annunziata, Chieti (Schips Luigi); Polo Pontino - Ospedale ICOT, Latina (Carbone Antonio); Presidio Ospedaliero "Vittorio Emanuele", Gela (Condorelli Sebastiano); Policlinico “Vittorio Emanuele”, Catania (Morgia Giuseppe); Presidio Ospedale S.S. Pietro e Paolo, Borgosesia (Cipollone Giovanni), Presidio Ospedaliero Carlo Poma, Mantova (Dall'Oglio Bruno) Presidio Ospedaliero CTO - Unità Spinale Struttura di Neuro Urologia, Torino (Carone Roberto); Presidio Ospedaliero di Brescia (Simeone Claudio); Presidio Ospedaliero di Busto Arsizio (Buizza Carlo); Presidio Ospedaliero di Pescara (Renzetti Roberto); Presidio Ospedaliero Mazzini, Teramo (Vicentini Carlo); Presidio Ospedaliero Occidentale, Castellaneta (Di Lena Sebastiano); Presidio Ospedaliero Perrino, Brindisi (Brigante Salvatore); Presidio Ospedaliero S. Andrea, Vercelli (Cipollone Giovanni); Ospedale S. Maria del Prato, Feltre (Xausa Daniele); Villa Pini D'Abruzzo, Chieti (Marascia Gabriele). Correspondence Fabio Parazzini, MD (Corresponding Author) fabio.parazzini@unimi.it Dipartimento di Scienze Cliniche e di Comunità, Università di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Via Commenda 12, 20122 Milano (Italy) Walter Artibani, MD segreteria@siu.it Società Italiana di Urologia (SIU), Roma (Italy) Giuseppe Carrieri, MD giuseppe.carrieri@unifg.it Dipartimento Nefro/Urologico Clinica Urologica e Centro Trapianti di Rene Università degli Studi di Foggia (Italy) Luca Carmignani, MD luca.carmignani@unimi.it Università degli Studi di Milano, Unità Operativa Complessa Ospedale Policlinico San Donato, Milano (Italy) Salvatore Voce, MD salvatore.voce@auslromagna.it Divisione di Urologia Ospedale Santa Maria delle Croci, Ravenna (Italy) Parazzini_Stesura Seveso 14/01/20 12:44 Pagina 250