Bipolar plasma TURP of prostate of 150 ml: The white resection

==inizio abstract==

The video shows the synthesis of a 70 minutes TURP of a prostate with a volume of 150 ml performed using the bipolar plasma edge technology by Lamidey. TURP remains the gold standard and it is strongly recommended for the treatment of moderate-to-severe LUTS men with prostate size of 30-80 mL. Oversized prostates > 80-100 mL undergo to traditional open prostatectomy or to laser enucleation. The TURP shown is one of a group of 7 patients with prostate larger than 100 ml and up to 180 ml treated by bipolar plasma TURP since November 2018. The approach for those oversized prostate was posterior to remove first the large medium lobe. For the lateral lobes a tunnel between the lobe and the prostate capsule was made to allow a faster and less bleeding resection of each lobe from the lateral to the median part. Average operative time was 71 minutes (range 55-90); mean hospitalization time was 3.3 days (range 2-4); no patient had TUR syndrome; none required blood transfusion or iron intravenous implementation; no other adverse event were registered. The use of saline solution and the short operative time allow the procedure to be safe also for large size prostate. Larger studies are mandatory to confirm our results.

==fine abstract==

DETRUSOR UNDERACTIVITY: ARE DIFFERENT DIAGNOSTIC CRITERIA OFTEN RELIABLE IN CLINICAL PRACTICE?

==inizio objective==

Detrusor underactivity (DU) is a common clinical problem in patient being referred with lower urinary tract symptoms (LUTS). DU is defined as a contraction of reduced strenght and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span (ICS in 2003). However, the majority of published criteria concentrate on detrusor strenght with the combinations of maximal flow rate (Qmax) and maximal detrusor pressure at Qmax (Pdet/Qmax) resulting incomplete consequence with regarde to definition perspective. Finally, many other tools have been proposed with the aim of chacterizing DU, but specific recommendations have been made on this regarding.
The aim of our study is to evaluate the diagnostic performance of different DU definitions in a large cohort of patients undergoing urodynamic study.

==fine objective==

==inizio methodsresults==

We prospectively collected data of patients receiving urodynamic examination from February 2010 to September 2018 according to EAU guidelines. Urodynamic exam has been performed on the basis of ICS recommendations. DU has been considered as the presence of a defined as detrusorial pressure (pDet)/Qmax < 30 cmH20 and it has been considered as the reference variable. We also calculated different variables including: bladder contractility index (BCI), watt factor (WF) and bladder voiding efficiency (BVE). The following cut-offs have been considered as suggestive for DU according to previious literature data: BCI < 100, BVE < 100, WF80 < 10

==fine methodsresults==

==inizio results==

In total, 792 patients have been included, 65.1% male and 34.9% female. The median age was 63.0 yrs (interquartile range: 47.0-71.0). 232 pts (29.29%) had a Pdet/Qmax < 30 cmH20, 590 (74.49%) had a BVE < 100, 370 (46.72%) had a BCI < 100 while 540 (68.2%) had a WF80 < 10. The agreements using the kappa Cohen’s coefficients between PdetQmax and the other parameters were as following: with BCI was 77.53% (p<0.01), with BVE was 36.87% (p=0.98) and with WF80 was 48.66% (p<0.01). At the univariate logistic regression analysis, BCI < 100 (odds ratio [OR]: 26.96; p<0.01), BVE < 100 (OR: 1.44; p=0.03) and WF80 < 10 (OR: 5.35; p<0.01) were associated with PdetQmax < 30 cmH20. We performed a bivariate logistic regression combining BCI < 100 with the other parameters and we showed that BCI (OR 0.94; p<0.01) and W80 (OR: 0.89; p=0.02) were both associated with DU. Finally, the decision curve analysis showed clinical benefit of BCI in predicting DU, with slightly increase in net benefit of BCI+WF80 over BCI.

==fine results==

==inizio discussions==

Finally, the decision curve analysis showed clinical benefit of BCI in predicting DU, with slightly increase in net benefit of BCI+WF80 over BCI. We found that BCI and WF80 exhibited agreement with PdetQmax for assessing DU and that combining both variables add clinical benefit in predicting DU.

==fine discussions==

==inizio conclusion==

We found that BCI and WF80 exhibited agreement with PdetQmax for assessing DU and that combining both variables add clinical benefit in predicting DU. We suggest in improving definition of DU by investigating the clinical benefits of other variables for assessing DU.

==fine conclusion==

==inizio reference==

1: Zhang WY, Xia QX, Hu H, Chen JW, Sun YR, Xu KX, Zhang XP. [Analysis of
urodynamic study of female outpatients with lower urinary tract symptoms and
follow-up of the patients with detrusor underactive]. Beijing Da Xue Xue Bao Yi
Xue Ban. 2019 Oct 18;51(5):856-862

2: Matsukawa Y, Yoshida M, Yamaguchi O, Takai S, Majima T, Funahashi Y, Yono M,
Sekido N, Gotoh M. Clinical characteristics and useful signs to differentiate
detrusor underactivity from bladder outlet obstruction in men with non-neurogenic
lower urinary tract symptoms. Int J Urol. 2019 Sep 21

3:Hartigan SM, Reynolds WS, Dmochowski RR. Detrusor underactivity in women: A
current understanding. Neurourol Urodyn. 2019 Nov;38(8):2070-2076

==fine reference==

Treatment of large volume prostates with bipolar plasma TURP: preliminary results

==inizio objective==

Trans Urethral Resection of Prostate (TURP) remains still the gold standard and it is strongly recommended for the treatment of patient with moderate to severe LUTS (Lower Urinary Tract Symptoms) with prostate size of 30-80 mL.(1) Patients with oversized prostates > 80-100 mL undergo to traditional open prostatectomy or to a laser enucleation. Aim of our study is to analyze the surgical outcomes and the safety of bipolar plasma TURP extended to oversized prostate.

==fine objective==

==inizio methodsresults==

Since November 2018 we treated with bipolar plasma TURP seven patients with a prostate volume larger than 100 ml and up to 180 ml. The average age was 69 years (range 51-80); the average prostate size, measured before the procedure by ultrasound, was 137 mL (range 100-180); at the moment of the procedure 4 patients had a bladder catheter (1 suprapubic and 3 transurethral), 2 had history of acute urinary retention, and 1 had severe LUTS and Qmax of 8 ml/s at the uroflowmetry; all of them previously received pharmacological treatment for LUTS (1 only dutasteride, 1 only alpha blocker, and 5 combined therapy with alpha blocker and dutasteride).
The TURP was performed using the bipolar plasma edge technology by Lamidey Noury Medical, saline solution as medium, instrument for resection with continuous irrigation system, and high definition video camera and 16:9 high definition monitor. The approach for those oversized prostate was modified, mainly it was a posterior approach to remove first the large medium lobe and then the lateral lobes. The medium lobe was first isolated between 2 tunnels at 5 and 7 o’clock deep to the capsule and extended to apex preserving the veru montanum; the resection was than performed between the 2 tunnels going parallel to the posterior wall, from one side to the other, and upward to downward. For both the large lateral lobes a deep tunnel between the lobe and the prostate capsule (starting at 1 o’clock for the left lobe down to almost 4 o’clock; and at 11 o’clock for the right lobe down to almost 8 o’clock) was first made in order to allow the resection of each lobe from the lateral side to the median part.

==fine methodsresults==

==inizio results==

Average operative time was 71 minutes (range 55-90); mean hospitalization time was 3.3 days (range 2-4); no patient had TUR syndrome neither serum sodium level drop, neither serum sodium level drop; no one required blood transfusion or iron intravenous implementation; no other adverse events were registered. Catheter was removed after 9.6 days (range 3-18) and all of them could void again. After 2 months, one patient, who suffered also Parkinson’s disease preferred to have the catheter indwelled again to better manage, according to his opinion, the relapse of severe LUTS.

==fine results==

==inizio discussions==

The bipolar plasma TURP was performed using normal saline solution (NaCl 0.9%) as fluid for continuous irrigation, instead of a nonconductive solution, offering the advantage of minimal absorption by the open vessels and eliminating the risk of electrolytic disorders, both TUR syndrome and the serum sodium level drop.(2)
The resection with the bipolar plasma edge technology is faster with less bleeding because of the attitude of the instrument to cut, vaporize and coagulate smaller vessels at the same time. After the cutting the prostate tissue looks white, not carbonized and it is still soft for further cuttings.
We believe that the modified approach for the large lateral lobes gives 2 other important advantages. One is to set immediately the capsular limit of the resection. The second is to create a flap from the lateral lobe which is already ischemized and ready to be fast removed by lateral to median resection going from upward to downward.
We believe that both the ultimate plasma technology and the modified approach contributed to a faster and less bleeding resection, allowing a safe operative time for those oversized prostate with volume up to 180 mL.

==fine discussions==

==inizio conclusion==

According to other authors (3) the treatment of oversized prostate with bipolar plasma TURP is an effective endoscopic technique and seems to offer surgical results equivalent to those encountered for smaller prostate volumes.
The use of saline solution and short operative time confirm the safety of the procedure also for large size prostate. In our single center study bipolar plasma TURP represents a valid alternative to open prostatectomy in large benign prostatic hyperplasia < 180 mL, up today. Because of the low cost comparable to standard TURP, it may be used in centers that do not have yet laser equipment. Larger studies and longer follow up are mandatory to confirm our results.

==fine conclusion==

==inizio reference==

1) https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts
2) Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (TURP). Omar MI, Lam TB, Alexander CE, Graham J, Mamoulakis C, Imamura M, Maclennan S, Stewart F, N'dow J. BJU Int. 2014 Jan;113(1):24-35. doi: 10.1111/bju.12281. Epub 2013 Oct 24. Review.
3) A Prospective Study of Bipolar Transurethral Resection of Prostate Comparing the Efficiency and Safety of the Method in Large and Small Adenomas.Mertziotis N, Kozyrakis D, Kyratsas C, Konandreas A. Adv Urol. 2015;2015:251879. doi: 10.1155/2015/251879. Epub 2015 Dec 7.

==fine reference==

Effects of Protoves- M1® on the prevention and the treatment of irritative symptoms after GreenLight laser photoselective vaporization (PVP) of benign prostatic hyperplasia (BPH)

==inizio objective==

The aim of this study was to analyse the role of two alkaloid, Protopine and Nuciferine (Protoves-M1®) in the prevention and the treatment of irritative symptoms (urgency and dysuria) after GreenLight laser photoselective vaporization (PVP) of benign prostatic hyperplasia (BPH)1.

==fine objective==

==inizio methodsresults==

Between July 2017 to September 2019, 120 patients with benign prostatic hyperplasia whose underwent GreenLight laser photoselective vaporization were prospectively randomized into two groups (Group A=Protoves M1® syrup, 10 ml, once a day, for 6 weeks; Group B= placebo (flavoured coloured water), 10 ml, once a day, for 6 weeks). They started therapy two weeks before the surgery. The primary endpoint was the evaluation of the efficacy of the therapy with Protoves M1® in controlling of the irritative symptoms.
The patients were evaluated at baseline (the day after removal of vesical catheter) and after 4 weeks (six weeks of therapy). All patients underwent IPSS (International Prostatic Symptoms Score) questionnaire, OverActive Bladder questionnaire-short form (OABq-SF) 6 and 13 and patient perception of intensity of urgency scale (PPIUS). Improvement was evaluated with the Patient Global Impression of Improvement questionnaire (PGI-I), that is a global index that may be used to rate the response of a condition to a therapy. PGI-I was evaluated at 4 weeks follow-up.

==fine methodsresults==

==inizio results==

The two groups showed no differences in terms of patients’ demographics as well as baseline characteristics in all variables analysed (p>0.05). No significant differences were seen in the baseline results of questionnaires in the two groups (p>0.05).
The patients of Group A showed a better IPSS score (p<0.001), a better control of urgency symptoms (PPIUS) (p=0.020) and a better OAB1-SF 6 (p=0.001) and 13 (p=0.001) than Group B at 4 weeks follow-up (Table 1).
PGI-I demonstrated a better satisfaction of the treatment in the group A than in the Group B (p<0.001).

==fine results==

==inizio discussions==

The Greenlight laser is a continuous wave laser which initially used a potassium titanyl phosphate (KTP) crystal to produce a light beam at a wavelength of 532 nm. This wavelength is selectively absorbed by oxyhemoglobin in prostatic tissue at a power level of 80 W, allowing for tissue photovaporization with a short depth of penetration. Despite this, irritative symptoms including prolonged urgency and dysuria after GreenLight laser photoselective vaporization (PVP) of benign prostatic hyperplasia (BPH) are common complication. In our experience, these symptoms self improved after some months. The use of Protoves-M1 before and after surgery improved the control of these irritative symptoms as demonstrated by the questionnaires administrated to our patients.
Protopine has a confirmed anticholinergic-antimuscarinic2 and GABAergic3 action and it can impact some neurological systems responsible of bladder functions. Nuciferine is a partial antagonist of D2-like receptor and has a well established regulatory action on the dopaminergic system (responsible of urination onset4). Moreover Nuciferine has a role in reducing states of tension and anxiety on a psychological level5. In addiction, Nuciferine reduce inflammation by inhibiting TLR4/PI3K/NF-κB signaling.

==fine discussions==

==inizio conclusion==

Protoves M1® can be an interesting alternative to antinflammatory agents to treat irritative symptoms of GreenLight laser photoselective vaporization of benign prostatic hyperplasia.

==fine conclusion==

==inizio reference==

1-Sun I, Yoo S, Park J, et all. Quality of life after photo-selective vaporization and holmium-laser enucleation of the prostate: 5-year outcomes. Sci Rep. 2019 Jun 4;9(1):8261.
2-Ustunes L., Laekeman GM, Gözler B, Vlietinck AJ, Ozer A, Herman AG. In Vitro Study of the anticholinergic and antihistaminic activities of Protopine and some derivatives. Journal of Natural Products, 1988
3-Kardos J., Blaskó G, Simonyi M. Enhancement of gamma-aminobutyric acid receptor binding by protopine-type alkaloids. Arzneimittelforschung, 1986
4-Fowler C.J., Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci. 2008 Jun; 9(6): 453–466.
5-Kang M., Shin D, Oh JW, Cho C, Lee HJ, Yoon DW et al. The Anti-Depressant Effect of Nelumbinis Semen on Rats under Chronic Mild Stress Induced Depression-Like Symptoms. Am J Chin Med., 2005

==fine reference==

Use of a complexed nutraceutical product based on flower pollen extract, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin PP and folic acid to lower prostate-specific antigen (PSA) levels in patients with asymptomatic benign prostate hyperplasia (BPH)

==inizio objective==

“Modern” nutraceutical products are frequently used in uro-andrology [1,2]. Medicinal plants are excellent devices for the treatment of symptoms due to benign prostate hyperplasia (BPH) and other urological disorders (e.g., chronic pelvic pain syndrome and chronic prostatitis) [3] thanks to their antioxidant, anti-proliferative and anti-inflammatory effects [4,5]. The aim of our study is to determine efficacy of complexed nutraceutical product based on flower pollen extract, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin PP and folic acid to lower of prostate-specific antigen (PSA) with values between 4 and 10 ng/ml (so-called “gray zone”) in patients with asymptomatic BPH.

==fine objective==

==inizio methodsresults==

26 men aged 60.53 (SD=4.24), mean PSA 7.35 ng/ml (SD=2.91), affected by asymptomatic BPH were treated with a nutraceutical product containing flower pollen extract and a multivitamin complex for three months. The therapeutic protocol provided for the administration of 2 tablets a day (together) to take 30 minutes before the main meal. Inclusion criteria were defined as follows:
 total PSA in a range of 4.0-10.0 ng/ml;
 prostate volume <50 ml (by suprapubic ultrasound);
 digital rectal examination (DRE) negative for suspicious nodularity of gland;
 past medical history negative for previous pelvic surgery;
 no therapies in course with other phytotherapeutic agents, alpha-blockers, inhibitors of 5-alpha reductase (5-ARI), antibiotics by systemic route or anti-inflammatory drugs;
 absence of stone in bladder (by ultrasound assessment);
 negativity to Chlamydia Trachomatis test, Ureaplasma Urealyticum and Neisseria Gonorrhoeae;
 International Prostate Symptom Score (I-PSS) equal to zero.

==fine methodsresults==

==inizio results==

The dosage of PSA was performed at laboratories of our hospital at the time of the enrollment visit, at the first visit (D0), at the first check-up visit after 90 days (D90) and at the second check-up visit after 120 days (D120).
At D90 the PSA in 18 patients had a reduction of 33.5% and in 3 patients had a reduction of 15.3%. In one patient, the PSA did not have a significant reduction (0.9%), while in 4 patients there was a 39.3% increase. For this reason, these patients left the protocol and were subjected to multiparametric magnetic resonance imaging (mpMRI) using the Prostate Imaging-Reporting and Data System (PI-RADS) v2.1. In 3 patients PI-RADS score was 3, while in one patients the score was 4.
At D120 the PSA has remained stable in all patients without significant changes, while in 3 patients there was a slight increase (1.4%). No gastric or general side effects have been noticed during whole clinical study.

==fine results==

==inizio discussions==

Flower pollen extracts have provided evidence for efficacy and tolerability for the treatment of BPH and chronic prostatitis. Flower pollen extract is an effective anti-inflammatory nutraceutical product, thanks to inhibition of prostaglandin and leukotrienes synthesis as well as the inhibition of many cytokines as NF-kB (nuclear factor kappa-light-chain-enhancer of activated B cells) [6]. Lowering of PSA levels it can be useful to discriminate patients with asymptomatic BPH from those who need further tests like mpMRI or prostate biopsy. A limitation of the study was the low number of the patients. More randomized studies should be carried out to clarify the precise role of these active ingredients and their interactions.

==fine discussions==

==inizio conclusion==

In literature, flower pollen extracts and other nutraceutical products have shown the improvement of urinary symptoms and overall quality of life of patients affected by BPH [7]. This can be demonstrated with a significant reduction in PSA as an index of prostate inflammation. Therefore, this therapy can be useful to discriminate against patients with PSA in "gray zone" who need further assessments.

==fine conclusion==

==inizio reference==

1. Allkanjari O, Vitalone A. What do we know about phytotherapy of benign prostatic hyperplasia? Life Sci. 2015 Apr 1;126:42-56. doi: 10.1016/j.lfs.2015.01.023. Epub 2015 Feb 20.
2. Pagano E, Laudato M, Griffo M, Capasso R. Phytotherapy of benign prostatic hyperplasia. A minireview. Phytother Res. 2014 Jul;28(7):949-55.3
3. Maurizi A, De Luca F, Zanghi A, Manzi E, Leonardo C, Guidotti M, Antonaccio FP, Olivieri V, De Dominicis C. The role of nutraceutical medications in men with non bacterial chronic prostatitis and chronic pelvic pain syndrome: A prospective non blinded study utilizing flower pollen extracts versus bioflavonoids. Arch Ital Urol Androl. 2019 Jan 18;90(4):260-264.
4. Cicero AFG, Allkanjari O, Busetto GM, Cai T, Larganà G, Magri V, Perletti G, Robustelli Della Cuna FS, Russo GI, Stamatiou K, Trinchieri A, Vitalone A. Nutraceutical treatment and prevention of benign prostatic hyperplasia and prostate cancer. Arch Ital Urol Androl. 2019 Oct 2;91(3).
5. Pirola GM, Puliatti S, Bocchialini T, Martorana E, Micali S, Bianchi G. Efficacy of pollen extract in association with group B vitamins for pain relief in chronic prostatitis/chronic pelvic pain syndrome: A survey of urologists' knowledge about its clinical application. Arch Ital Urol Androl. 2017 Mar 31;89(1):22-25.
6. Cai T, Verze P, La Rocca R, Anceschi U, De Nunzio C, Mirone V. The role of flower pollen extract in managing patients affected by chronic prostatitis/chronic pelvic pain syndrome: a comprehensive analysis of all published clinical trials. BMC Urol. 2017 Apr 21;17(1):32.
7. Macchione N, Bernardini P, Piacentini I, Mangiarotti B, Del Nero A. Flower Pollen Extract in Association with Vitamins (Deprox 500®) Versus Serenoa repens in Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Comparative Analysis of Two Different Treatments. Antiinflamm Antiallergy Agents Med Chem. 2019;18(2):151-161.

==fine reference==

EFFICACY OF GREEN LIGHT LASER PVP IN PATIENTS WITH BLADDER NECK SCLEROSIS. OUR EXPERIENCE

==inizio objective==

GREEN LIGHT LASER IS A NOTICEABLE SURGICAL OPTION TO TREAT BPE MOREOVER IN PATIENTS WITH COMORBILITIES AS COAGULOPATHIES OR MEDICAL TREATMENTS WITH ANTIPLATELET OR ANTICOAGULANT. IN OUR STUDY WE AIM TO DEMONSTRATE THE EFFICACY OF PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE (PVP) AS A TREATMENT OF BLADDER NECK SCLEROSIS AFTER PROSTATE SURGERY

==fine objective==

==inizio methodsresults==

WE PROSPECTIVELY COLLECTED DATA ABOUT PATIENTS WITH VOIDING LOWER URINARY TRACTS SINTOMS LUTS AFTER ENDOSCOPIC PROSTATE SURGERY. BLADDER NECK SCLEROSIS WAS IDENTIFIED WITH A STANDARD CYSTOSCOPHY. WE COLLECTED DATA ABOUT UROFLOWMETRY. ALL PATIENT UNDERWENT SURGICAL PVP WITH GREEN LIGHT LASER, THE PROCEDURE WAS PERFORMED WITH A 600 MICRON FIBRE HAVING A 532 NM WAVELENGHT INSERTED IN AN IGLESIAS 26 CH CYSTOSCOPE WITH A 0 DEGREES LENS, AS IRRIGANT WAS USED NACL 0.9% SOLUTION. THE FIBRE ACTIONS IS ACHIEVED AT AN ANGLE OF 90 DEGREES FROM THE END OF THE FIBRE WITH A “PAINT BRUSH FASHION” MOVEMENT NEAR THE TISSUE RESOULTING IN A PHOTOVAPORIZATION OF THE POINTED SITES. IN CASE OF BLEEDINGS WE PERFORMED A COAGULATION WITH A POWER SETTING OF 30 WATTS. AT THE END OF THE PROCEDURE A DUFOUR 22 CH CATHETHER WAS INSERTED IN THE BLADDER. WE CONSIDERED AS A SUCCESFULL RESPONSE AN IMPROVEMENT OF UROFLOWMETRY PARAMETERS POST OPERATIVELY COMPAIRED WITH PREOPERATIVELY ONES.

==fine methodsresults==

==inizio results==

WE ENROLLED 17 PATIENTS WITH BLADDER NECK SCLERORIS. ALL PATIENTS UNDERWENT PVP PERFORMED WITH SPINAL ANESTESIA. MEDIAN SURGICAL TIME WAS < 10 MINUTES AND MEDIAN HOSPITAL STAY WAS 1 DAY. THE MEDIAN FOLLOW UP WAS MONTS. ALL PATIENTS HAD AN IMPROVEMENT OF UROFLOWMETRY PARAMETERS IDENTIFIED AS A HIGHER QMAX FROM 5 ML/S TO 26 ML/S POST OPERATIVELY. NO ADVERSE EFFECTS WERE RECORDED DURINNG THE PROCEDURE. NO ADVERSE EFFECTS WERE RECORDED DURING THE HOSPITAL STAY, AND DURING FOLLOW UP. NO PATIENTS REQUIRED SECOND TREATMENTS OR CATETHERIZATION AFTER THE PROCEDURE

==fine results==

==inizio discussions==

GREEN LIGHT LASER IN A SURGICAL TREATMENT COMMONLY USED FOR BPH. KUMAR ET ALL.[1] IN THEIR STUDY SHOWED THAT PVP TREATMENT WAS COMPARABILY IN EFFICACY WITH MONOPOLAR TURP AND BIPOLAR TURP IN 201 PATIENT WITH A SUCCESS RATE OF 63% IN IPSS SCORE AND 55% IN QOL WITH A 36 MONTHS FOLLOW UP. A META-ANALISIS LAI ET ALL [2]SHOWED A QOL IMPROVEMNT OF 95% IN PATIENTS TREATED WITH PVP VS TURP WITH LOWER ADVERSE EFFECT (THEY REPORTED FEW CASES OF DYSURIA AND REINTERVENTION MANAGED WITH NO INVASIVE TECNIQUEAND, THE ONLY LIMITATION IDENTIFIED WAS THE IMPOSSIBILITY OF HISTOLOGICAL TISSUE EXAMINATION WITH). THERE IS A LACK OF EVIDENCE IN LITERATURE DEALING WITH LUTS CAUSED BY BLADDER NECK SCLERORIS IN MALE.. IN OUR STUDY WE CONSIDERED MALE PATIENTS WITH BLASSER NECK SCLEROSIS TREATED WITH PVP WITH A SUCCESS RATE OF AND NO ADVERSE EFFECTS. THE LIMITATION OF OUR STUDY ARE THE FEW NUMBER OF PATIENTS, THE IMPOSSIBILITY OF AN HISTOLOGICAL EXAMINATION OF THE TISSUE.

==fine discussions==

==inizio conclusion==

PVP MAY BE A SAFE AND EFFICENT TREATMENT OPTION FOR BLADDER NECK SCLEROIS .

==fine conclusion==

==inizio reference==

1. Kumar A, Vasudeva P, Kumar N, et al (2013) A Prospective Randomized Comparative Study of Monopolar and Bipolar Transurethral Resection of the Prostate and Photoselective Vaporization of the Prostate in Patients Who Present with Benign Prostatic Obstruction: A Single Center Experience. J Endourol 27:1245–1253. https://doi.org/10.1089/end.2013.0216
2. Lai S, Peng P, Diao T, et al (2019) Comparison of photoselective green light laser vaporisation versus traditional transurethral resection for benign prostate hyperplasia: an updated systematic review and meta-analysis of randomised controlled trials and prospective studies. BMJ Open 9:. https://doi.org/10.1136/bmjopen-2018-028855
3. Sharifian H, Zargham M, Khorami MH, et al (2019) Internal Urethrotomy in Treatment of Female with Anatomical Bladder Outlet Obstruction. Adv Biomed Res 8:. https://doi.org/10.4103/abr.abr_200_18

==fine reference==

LEARNING CURVE OF PVP WITH GREEN LIGHT LASER: IS LONGER IN PATIENTS WITH BLADDER CATHETHER?

==inizio objective==

LEARNING CURVE IS A TREATING ARGUMENT IN UROLOGICAL SURGERY, IS DEFINED AS THE NUMBER OF PROCEDURE TO GET INTRAOPERATIVE PARAMETER PLATEAU REGARDLESS OF SURGEON EXPERTISE AND INSTITUTIONAL BACKGROUND. THE AIM OF OUR STUDY IS TO SHOW THE DIFFERENCE FOR THE SURGEON DURING LEARNING CURVE TO GET TO THE PLATEAU FOR THE PVP WITH GREEN LIGHT LASER IN TWO GOUPS OF PATIENS WITH BPE/LUTS: PATIENTS WITH BLADDER CATHETHER FOR URINARY RETENTION AND PATIENTS WITH NO NEED OF CATHETERIZATION.

==fine objective==

==inizio methodsresults==

WE PROSPECTIVELY COLLECTED DATA FROM OUR CENTER DATABASE. WE ENROLLED PATIENTS WITH BPE/ LUTS UNRESPONDERS TO CONSERVATIVE TERAPHY (ALFA BLOCKERS AND/0R 5ARI) WITH IPSS > 20. WE DIVIDED THE PATIENTS IN TWO GROUPS: GROUP 1 PATIENTS WITH CATHETHER. GROUP 2 : PATIENTS WITHOUT CATETHER. WE COLLECTED DATA ABOUT DEMOGRAPHICS, TYPE OF TREATMENT BEFORE PROCEDURES, IPSS BEFORE AND AFTER PROCEDURE, PSA LEVEL, PROSTATE VOLUME. ALL PATIENTS UNDERWENT STANDARD GREEN LIGHT LASER PHOTOSELECTIVE VAPORISATION OF THE PROSTATE, THE PROCEDURE IS PERFORMED WITH A 600 MICRON FIBRE HAVING A 532 NM WAVELENGHT INSERTED IN AN IGLESIAS 26 CH CYSTOSCOPE WITH A 0 DEGREES LENS, AS IRRIGANT WAS USED NACL 0.9% SOLUTION. THE FIBRE ACTIONS IS ACHIEVED AT AN ANGLE OF 90 DEGREES FROM THE END OF THE FIBRE WITH A “PAINT BRUSH FASHION” MOVEMENT NEAR THE TISSUE RESOULTING IN A PHOTOVAPORIZATION OF THE POINTED SITES. IN CASE OF BLEEDINGS WE PERFORMED A COAGULATION WITH A POWER SETTING OF 30 WATTS. AT THE AND OF THE PROCEDURE A DUFOUR 22 CH CATHETHER WAS INSERTED IN THE BLADDER. WE ANALIZED THE LEARNING CURVE IN TERMS OF: OPERATIVE TIMES, THE ENERGY DELIVERED/THE PROSTATE VOLUME TRYING TO ACHIEVE THE, DEFINED BY LITERATURE, STANDARD OF EXPERTISE: TO REACH AN AVERAGE ENERGY OF 5 KJ/1 CC OF PROSTATE VOLUME

==fine methodsresults==

==inizio results==

WE ENROLLED 42 PATIENTS WITH BPE/LUTS WE DIVIDED PATIENT IN TWO GROUPS GROUP 1 PATIENTS WITH CATHETHER (N=17), GROUP 2 WITHOUT CATETHER (N=25). PATIENTS PREOPERATIVELY CARATHERISTICS WERE SIMILAR,MEDIAN PROSTATE VOLUME WAS GROUP 1 45 CC, GROUP 2 55 CC, MEDIAN IPSS WAS 23. WE REPORTED DIFFERENCES IN VAPORITATION TIMES BETWEEN THE TWO GOUPS GROUP 28 MINUTES,GROUP 2 19 MINUTES; ENERGY DELIVERED GROUP 1 245 KJ ,GROUP 2 187 KJ. THE ENERGY DELIVERED/THE PROSTATE VOLUME RATIO GROUP 1: 8 KJ/CC) , GROUP 2: 4,6 KJ/CC. THE TWO GROUPS SHOWED STATISTICALLY SIGNIFICANT DIFFERENCE THAT AFFECTS THE LEARNING CURVE, THE GROUP 1 PATIENTS REQUIRED MORE EXPERTIZE HIGHLIGHTED AS LONGER OPERATIVE TIMES. HIGHER THE ENERGY DELIVERED/THE PROSTATE VOLUME RATIO SHOWING THAT TO GET A PLATEAU SURGEON NEEDS MORE PROCEDURE WHEN THE PATIENT IS A BLADDER CATHETHER CARRIER

==fine results==

==inizio discussions==

LEARNING CURVE IN UROLOGY IS CHALLENGING THE PLATEAU IS DEFINED BY LITERATURE AS DELIVERING AN AVERAGE ENERGY OF 5 KJ PER ML OF PROSTATE VOLUME [1]AND REACHING A LT/OT RATIO OF 66–80 %[2]. BASTARD ET AL. IN THEIR STUDY SHOWED THAT SURGEONS NEEDED MORE THAN 100 PROCEDURES TO GET A PLATEAU WHEN USING GREEN LIGHT LASER PVP, WITH NO HIGHLIGHTS OF PATIENTS CHARATERISTICS AS A VARIABLE AFFECTING THE LEARNING CURVE[3]. MISRAI ET ALL. IN THEIR STUDY SHOWED THAT 120 PROCEDURE ARE NECESSARY TO ACHIEVE THE STANDARDS OF LITERATURE, RATIO OF JOULES/ML INCREASED EVERY 10 PROCEDURE BY A MEAN OF 14 J/ML. THE LITERATURE STANDARDS IN THEIR EXPERIENCE WAS REACHED AT THE 75TH PATIENT. IN THEIR EXPERIENCE THE LT/OT RATIO EVERY 10 PATIENTS INCREASED BY A MEAN OF 1.2 % UNLINKED WITH PROSTATE VOLUME, LT/OT RATIO OF 75 % WAS REACHED BY THE 125TH PROCEDURE, WITH A 6% OFPROCEDURE CONVERTION TU TURP.
IN OUR EXPERIENCE WE NOTICED THE DIFFERENCE IN REACHING LEARNING CURVE PALTEAU WAS AFFECTED BY PATIENTS’ CARATHERISTICS. WE SHOWED A DIFFERENCE STATISTICALLY SIGNIFICATIVE IN TERMS OF NUMBER OF PROCEDURES NEEDED TO GET TO EXPERTIZE STANDARDS WHEN PATIENS HAVE INDWELLING CATHETERS

==fine discussions==

==inizio conclusion==

OUR STUDY SHOWS THAT PATIENTS CARATHERISTICS, MOREOVER THE INDWELLING CATHETER IS A PARAMETER THAT AFFECTS IN A NEGATIVE WAY THE REACHING OF THE LITERATURE STANDARD OF EXPERTIZE SLOWING THE SURGEON LEARNING CURVE.

==fine conclusion==

==inizio reference==

1. Bachmann A, Muir GH, Collins EJ, et al (2012) 180-W XPS GreenLight Laser Therapy for Benign Prostate Hyperplasia: Early Safety, Efficacy, and Perioperative Outcome After 201 Procedures. Eur Urol 61:600–607. https://doi.org/10.1016/j.eururo.2011.11.041
2. Capitán C, Blázquez C, Martin MD, et al (2011) GreenLight HPS 120-W Laser Vaporization versus Transurethral Resection of the Prostate for the Treatment of Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia: A Randomized Clinical Trial with 2-year Follow-up. Eur Urol 60:734–739. https://doi.org/10.1016/j.eururo.2011.05.043
3. Bastard C, Zorn K, Peyronnet B, et al (2019) Assessment of Learning Curves for 180-W GreenLight XPS Photoselective Vaporisation of the Prostate: A Multicentre Study. Eur Urol Focus 5:266–272. https://doi.org/10.1016/j.euf.2017.09.011

==fine reference==

URETROTHOMY SEC. OTIS WITH LOCAL ANESTESIA. IS IT POSSIBLE?

==inizio objective==

URETHROTHOMY SEC. OTIS IS A COMMON UROLOGICAL PROCEDURE PERFORMED WITH SPINAL ANESTESIA, IN OUR CENTER WE PERFORMED FOR THE FIRTS TIME THE PROCEDURE WITH LOCAL ANESTESIA: DORSAL PENILE NERVE BLOCK AND RING BLOCK AT THE BASE OF THE PENIS WITH SAME EFFICACY, NO PERI OPERATIVE PAIN, NO DIFFERENCE IN POST OPERATIVE PAIN COMPARING TO STANDARD PROCEDURE AND NO ADVERSE EVENT RELATED TO THE PROCEDURE

==fine objective==

==inizio methodsresults==

WE PROSPECTIVELY COLLECTED DATA FROM OUR CENTER DATABASE REGARDING PATIENTS TREATED WITH OTIS URETROTHOMY WITH DORSAL PENILE NERVE BLOCK.
ALL PATIENT UNDERWENT LOCAL ANESTESIA. DORSAL PENILE NERVE BLOCK [1]AT THE LEVEL OF THE PUBIC SYMPHYSIS AND RING BLOCK AT THE BASE OF THE PENIS WITH 10 CC OF LIDOCAINE 1% INJECTED WITH A 16 GAUGE NEEDLE. AFTER LOCAL ANESTESIA WE PERFORMED CLASSICAL OTIS URETROTHOMY A BLIND TRANS URETHRAL INCISION WITH OTIS URETHROME. WE INSERTED OTIS URETHROTOME IN THE URETHRA, THE URETHRA IS THEN DILATATED, STRECHED AND CUTTED AT 12 O’CLOCK IN ORDER TO ACHIEVE A SUFFICENT CALIBRUS. AT THE END OF THE PROCEDURE A FOLEY CATETHER IS POSITIONED INTO THE BLADDER. WE COLLECTED PRE AND POST OPERATIVE DATA ABOUT PATIENTS DEMOGRAFICS, IPSS SCORE PRE AND POST OPERATIVELY, WE PERFORMED A STANDARD CYSTOSCOPY TO DEFINE THE GRADE AND LENGHT OF THE STENOSIS AND A STANDARD UROFLOWMETRY PRE AND POST OPERATIVE.

==fine methodsresults==

==inizio results==

WE ENROLLED 19 PATIENTS WITH URETRAL STRICTURE FROM JANUARY 2019 TO OCTOBER 2019. MAIN AGE WAS 74 YEARS, MAIN FLUOMETRY PRE OPERATIVELY WAS QMAX: 5 ML/A; VV: 234 ML; PVR 60 ML, IPSS PRE OPERATIVELY WAS -. ALL PATIENTS UNDERWENT STANDARD CISTISCOPY PRE OPERATIVELY, ALL PATIENTS HAD A MEATAL (SUB)STENOSIS. STANDARD OTIS URETHROTOMY WAS PERFORMED UNDER LOCAL ANESTESIA, VAS SCALE AFTER THE PROCEDURE WAS 2. AT THE END OF THE PROCEDURE WE POSITIONED A FOLEY CATETHER IN THE OPERATORY ROOM KEPT FOR 7- 10 DAYS ACCORDING TO THE LENGHT OF STENOSIS.
POST OPERATIVELY UROFLOWMETRY RESOULT WAS QMAX 15 ML/S; VV ; PVR: 30 ML.
WE ACHIED A % OF SUCCESS IDENTIFIED AS BETTER UROFLOWMETRY VALUES AND NO EVIDENCY OF INCREASED PAIN LEVEL ANALIZED WITH VAS.

==fine results==

==inizio discussions==

S URETHROTOMY IS A STANDARD PROCEDURE USED BY UROLOGIST TO TREAT URETHRAL STRICTURE[2]. IN LITERATURE THERE IS A LACK OF EVIDENCE DEALING WITH THE PROCEDURES PAIN LEVEL. IT’S USUALLY PERFORMED UNDER SPINAL ANESTESIA, WE PERFORMED FOR THE FIRST TIME THE PROCEDURE WITH LOCAL ANESTESIA. COMMON KNOWN ADVERSE EFFECTS OF THE PROCEDURE WERE RECURRENCES OF THE STRICTURE, BLEEDING AND UNCOMMON ONES ERECTILE DYSFUNCTION AND URINARY INCONTINENCE. IN OUR EXPERIENCE WE REPORT NO ADVERSE EFFECTS. MAIN LIMITATION OF OUR STUDY WERE THE FEW NUMBER OF PATIENTS AND THE ABSENCE OF A CONTROL GROUP.

==fine discussions==

==inizio conclusion==

LOCAL ANESTESIA FOR OTIS URETROTHOMY MAY BE A VALID ALTERNATIVE WITH SAME EFFICACY AND NO INCREMANTATION OF PAIN LEVEL FOR THE PATIENTS. OUR STUDY SHOW ANALOGUOUS RESULTS IN CLINICAL OUTCOMES WITH AN IMPROVEMNT OF UROFLOUMETRY VALUES AND NO INCREASE IN PAIN LEVEL AFTER SURGERY .

==fine conclusion==

==inizio reference==

1. McPhee AS, McKay AC (2018) Dorsal Penile Nerve Block. StatPearls Publishing
2. Internal Urethrotomy – www.urology-textbook.com. http://www.urology-textbook.com/internal-urethrotomy.html. Accessed 24 Nov 2019

==fine reference==

LAPAROSCOPIC SIMPLE PROSTATECTOMY (LSP): PRELIMINARY EXPERIENCE

==inizio objective==

The surgical treatment of lower urinary tract symptoms (LUTS) by benign prostatic hyperplasia (BPH) includes traditional transurethral resection of the prostate (TURP), laser surgery and open prostatectomy [1]. Open prostatectomy, usually indicated for high volume adenoma, is sometimes burdened by significant morbidity. Recent advances in holmium laser enucleation of the prostate (HoLEP) and laser vaporization are mininvasive options widely used despite some limitations [2]. Laparoscopic simple prostatectomy (LSP) is an intriguing alternative to open surgery in the hands of experienced laparoscopic surgeon [3,4]. Here we present our single centre preliminary results using laparoscopic simple prostatectomy in the treatment of large benign prostatic hyperplasia (BPH), with the aim of discussing its feasibility and safety.

==fine objective==

==inizio methodsresults==

Between January 2018 and September 2019, 28 patients were submitted to laparoscopic simple prostatectomy. Patients were selected according to LUTS questionnaire (International Prostate Symptom Score, IPSS), digital rectal examination, transrectal ultrasound scan, uroflowmetry with post-voidal residue, PSA. Inclusion criteria were a prostate volume > 80 ml and/or presence of other conditions requiring surgical correction. All procedure were performed under general anesthesia. Surgical procedure was performed as an extraperitoneal adenomectomy according to Millin technique. The procedure was performed by using 3 operative trocars after dissection of Retzius space using a 0° optical lense connected to a 3D system. Adjunctive laparoscopic hernioplasty (3 pts), bladder lithotomy (3 pts) and bladder diverticolectomy (2 pts) were performed simultaneously when required. Demographic date and peri-operative results were analyzed.

==fine methodsresults==

==inizio results==

Mean age was 72 years (range 69-72 yrs). All procedure was performed laparoscopically and no patient required conversion to open surgery or re-surgery. The mean prostate volume was 105 ml (range 83-150 ml). Mean operative time was 130 minutes (range 110 -200 mins), while estimated blood loss was 190 ml (range 150-320 ml). Only one patient required blood transfusion. Mean hospital stay was 5.2 days (range 2-8) and mean catheterization time was 6.4 days (range 6-9). At 1 month follow up all patients were dry and potent.

==fine results==

==inizio discussions==

Our preliminary results show that LSP is feasible and safe, providing a short hospital stay with early return to normal activity. LSP has a low morbidity although it seems feasible and reproducible in high experienced laparoscopic centre [5]. As for open surgery, other advantage of LSP is the possibility of performing secondary procedures (as hernioplasty, bladder diverticulectomy and so on). The main disadvantage is the need of general anesthesia.

==fine discussions==

==inizio conclusion==

Laparoscopic Simple Prostatectomy (LSP) has a place in symptomatic and large benign prostatic hyperplasia (BPH) in the hands of experienced laparoscopic surgeons when open simple prostatectomy is needed. Despite the encouraging results, only long-term prospective and comparative studies will better define the role of LSP in high volume BPH.

==fine conclusion==

==inizio reference==

1. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2019. Foster HE, Dahm P, Kohler TS, Lerner LB, Parsons JK, Wilt TJ, McVary KT. J Urol. 2019 Sep;202(3):592-598

2. The role of minimally invasive surgical tecniques in the management of large-gland benign prostatic hypertrophy. Ganesh Sivarajan, Michael S. Borofsky, Ojas Shah. Rev Urol 2015;(3): 140-9

3. Laparoscopic extraperitoneal adenomectomy (Millin): pilot study on feasibility. Van Velthoven R, Peltier A, Laguna MP, Piechaud T. Eur Urol 2004;45(1): 103-9; discussion 109

4. The surgical treatment of a large prostatic adenoma; the laparoscopic approach-A systematic review. Asimakopoulos AD,Mugnier C, Hoepffner JL, Spera E. J endourol 2012 Aug; 26(8): 960-7

5. Perioperative outcomes of robotic and laparoscopic simple prostatectomy: a European -American Multi-institutional Analysis. Autorino R, Zargar H, Mariano MB, Sanchez-Salas R, Sotelo RJ, Chlosta PL, Castillo O, Matei DV, Celia A, Koc G, Vora A, Aron M, Parsons JK, Pini G, Jensen JC, Sutherland D, Cathelineau X, Nuñez Bragayrac LA, Varkarakis IM, Amparore D, Ferro M, Gallo G, Volpe A, Vuruskan H, Bandi G, Hwang J, Nething J, Muruve N, Chopra S, Patel ND, Derweesh I, Champ Weeks D, Spier R, Kowalczyk K, Lynch J, Harbin A, Verghese M, Samavedi S, Molina WR, Dias E, Ahallal Y, Laydner H, Cherullo E, De Cobelli O, Thiel DD, Lagerkvist M, Haber GP, Kaouk J, Kim FJ, Lima E, Patel V, White W, Mottrie A, Porpiglia F. Eur Urol. 2015 Jul;68(1):86-94.

==fine reference==

Urological-Geriatric Integrated Diagnostic-Therapeutic Pathway (PDTA) at Galliera Hospital in Genoa

==inizio objective==

Aim of our study is to identify patients at moderate/severe geriatric risk in order to create an appropriate clinical pathway, using the following tools:
1) Definition of a clinical and functional prognosis, before and after urological surgery using the Multidimensional Prognostic Index (MPI);
2) Modification of existing clinical risk conditions before and after surgery;
3) Early initiation of an appropriate social-assistential path for elderly patients undergoing urological surgery

==fine objective==

==inizio methodsresults==

At the Galliera Hospital in Genoa we have developed a Urological-Geriatric Integrated Diagnostic-Therapeutic Pathway (PDTA) for patiens aged ≥65 years affected by urogenital pathologies requiring major laparoscopic or open surgery: radical cystectomy, radical or partial nephrectomy, radical prostatectomy. These patients, in a presurgical outpatient context, receive a Selfy_MPI, which is a validated self-assessment questionnaire of multi-dimensional risk for negative outcomes validated for≥65 years patients.1
In case of Selfy_MPI class 2 (moderate risk) or 3 (high risk) the patient is addressed to the urogeriatric team, which consists of various professional figures who cooperate together (urologist, geriatrician, anesthesiologist, nurse, social worker). In particular, the geriatrician evaluate the patient for clinical history, functional assessment and calculation of MPI.
Compared to other frailty measurements, MPI shows an higher positive predictive value of adverse outcomes in hospitalized older patients.2
When the MPI score identifies a patient in a class risk 2 or 3 a specific assessment of the risk areas is required, in order to improve clinical and functional parameters, follow patient after surgery during hospitalization, plan specific postoperative geriatric and urologic follow-up after 3 or 6 months.

==fine methodsresults==

==inizio results==

The PDTA started on February 2019 and until October 2019 it has included 54 patients aged from 66 to 92 years old. All patients performed the Selfy_MPI. 46 patients showed a Selfy_MPI at a risk class 1; 8 patients resulted into the risk class 2, so they were evaluated by geriatricians that performed full MPI, confirming the risk class (MPI 2). 2 patients had an ASA score 4 and the anesthesiologist excluded surgery, 1 patient developed metastasis and began chemotherapy ; 2 patients refused surgery and 3 patients were considered able to be operated. 49 patients underwent open or laparoscopic surgery: 17 patients were submitted to radical prostatectomy (15 laparoscopic, 2 open surgery), 12 to radical cystectomy (2 laparoscopic, 10 open), 15 to radical nephrectmy or nephroureterectomy (7 laparoscopic, 8 open), 3 to laparoscopic partial nephrectomy, 1 to synchronous bilateral laparoscopic radical partial nephrectomy for synchronous renal cancer, 1 to open radical cystectomy with concomitant nephroureterectomy.

==fine results==

==inizio discussions==

Several sudies reported the effects of frailty on falls, hospitalization and mortality, but only few focused on surgical patients and frailty is not included in the traditional surgical risk scales.3
The most common definition of frailty is an age-associated, biological syndrome characterized by decreased biological reserve, due to dysregulation of several physiological systems, and poor outcomes.4
Frail patients have an higher risk of adverse outomes including prolonged hospitalization, mortality and disability. 4,5
The prevalence of frailty increases with age: in people older than 65 years ranging from 7 to 16.3%, reaching 30% of people aged 85 years. 6,7
Literature shows an improvement of clinical outcomes of elderly people urdergoing surgery when they undergo an evaluation of frailty with multidimensional assessment. 8
In our PDTA we used the MPI score for patients at risk of negative outcomes. MPI is a widely accepted prognostic tool, based on a standard Comprehensive Geriatric Assessment (CGA): multicenter studies demonstrated that MPI was a significantly more accurate predictor of all-cause mortality than other frailty index.9
The European Medicines Agency (EMA), in 2018 reported that the MPI is able to extract information from CGA to categorized frailty in three subgroups with excellent prognostic value.

==fine discussions==

==inizio conclusion==

The objective of our PDTA is to create for elderly patients an individual treatment plann based on frailty degree. The creation of PDTA provides a better customization of the clinical /diagnostic pathway and prognostic classification of the patients. The results we have obtained so far are still preliminary, however, the possibility of extend the PDTA to patients requiring endoscopic surgery will be evaluated.

==fine conclusion==

==inizio reference==

1. Development and Validation of a Self-Administered Multidimensional Prognostic Index to Predict Negative Health Outcomes in Community-Dwelling Persons. Pilotto A1, Veronese N1, Quispe Guerrero KL1, Zora S1, Boone ALD2, Puntoni M3, Giorgeschi A1, Cella A1, Rey Hidalgo I2, Pers YM4, Ferri A1, Fernandez JRH5, Pisano Gonzalez M6; EFFICHRONIC Consortium. Rejuvenation Res. 2019 Aug;22(4):299-305. doi: 10.1089/rej.2018.2103. Epub 2018 Dec 28
2. On behalf of the MPI_AGE Investigators Using the Multidimensional Prognostic Index to predict Clinical Outcomes of Hospitalizated Older Persons: a Prospective Multicentre. Pilotto A, Veronese N, Darajati J, et al. International Study. J Gerontol A Biol Sci Med 2018 (Epub ahead of print).
3.Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.Robinson TN1, Eiseman B, Wallace JI, Church SD, McFann KK, Pfister SM, Sharp TJ, Moss M. . Ann Surg. 2009 Sep;250(3):449-55.
4. Frailty in elderly people.Clegg A1, Young J, Iliffe S, Rikkert MO, Rockwood K. Lancet. 2013 Mar 2;381(9868):752-62. doi: 10.1016/S0140-6736(12)62167-9.
5. Importance of frailty in patients with cardiovascular disease. Singh M1, Stewart R2, White H2. Eur Heart J. 2014 Jul;35(26):1726-31
6. Frailty in older adults: evidence for a phenotype.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group.
J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56.
7. Older women are frailer, but less often die then men: a prospective study of older hospitalized people. Veronese N, Siri G, Cella A, Daragjati J, Cruz-Jentoft AJ, Polidori MC, Mattace-Raso F, Paccalin M, Topinkova E, Greco A, Mangoni AA, Maggi S, Ferrucci L, Pilotto A; MPI AGE Investigators. Maturitas. 2019 Oct;128:81-86
8. Frailty as a predictor of surgical outcomes in older patients. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. J Am Coll Surg. 2010 Jun;210(6):901-8.
9. Comparing the prognostic accuracy for all-cause mortality of frailty instruments: a multicentre 1-year follow-up in hospitalized older patients. Pilotto A1, Rengo F, Marchionni N, Sancarlo D, Fontana A, Panza F, Ferrucci L; FIRI-SIGG Study Group. PLoS One. 2012;7(1):e29090
10. Change in the Multidimensional Prognostic Index Score During Hospitalization in Older Patients. Volpato S, Daragjati J, Simonato M, Fontana A, Ferrucci L, Pilotto A. Rejuvenation Res. 2016 Jun;19(3):244-51

==fine reference==