Urology Unit

Ospedale San Raffaele

key figures 

CLINICAL SERVICES:

  • Treatment of Uro-Oncologic Pathologies
  • Treatment of Non-Oncologic Pathologies
  • Robotic Surgery
  • Endourology Surgery
  • Laparoscopic Surgery
  • MRI fusion prostate biopsy
  • Cystoscopy

PROCEDURES PERFORMED PER YEAR:

  • 3000 admissions
  • 2500 surgical interventions

The San Raffaele Department of Urology is composed of multiple subspecialty trained urologists, who have extended training in specialized surgical techniques.  It is ranked 1st among all the urological academic centres in Europe in terms of scientific publications. In particular the Unit is internationally recognised for the treatment of genitourinary tract tumours, prostatic hypertrophy, sexual dysfunction and male reproduction Specific experience has been acquired in the use of minimally invasive methods such as robotic surgery and Holmium laser.1

The exceptional range of our urologists' expertise allows us to provide innovative surgical services that in some cases aren't available anywhere else. Our skilled team of experts works collaboratively with other specialty areas at San Raffaele — including vascular surgery, internal medicine, gynaecology and oncology — to provide highly complex care, individualized to the needs of the patient.

Robotic, laparoscopy and open surgery are available techniques for the treatment of all the urological diseases. San Raffaele’s urological department is a worldwide known tertiary care centre for robotic prostatectomy, robotic cystectomy, robotic partial and radical nephrectomy, holmium enucleation of the prostate, laparoscopy and endourology and treatment of advanced and metastatic cases.
 

treatmentS

Uro-Oncologic Pathologies

Through the use of endoscopy, laparoscopic and robotics (DaVinci® system) or minimally invasive laparotomy techniques the following uro-oncologic diseases are treated.

  • Prostate Tumour

Prostate cancer is an asymptomatic disease in most cases and its diagnosis is more frequently incidental. For this reason, screening for prostatic neoplasia based on the measurement of PSA (the Specific Prostatic Antigen, measured in the blood) and rectal exploration (minimally invasive procedure that allows to evaluate the size, shape and consistency of the prostate). The treatments currently available for prostate cancer are numerous and the therapeutic choice is based on the characteristics of the patient and the disease itself. The standard treatment for prostate cancer, in the patient with a life expectancy of more than 10 years, is surgery, which consists of the complete removal of the prostate, seminal vesicles and possibly of the loco-regional lymph nodes. The goal of the surgical intervention is the complete eradication of the disease, preserving urinary continence and erectile function as much as possible.

Radiotherapy remains a valid therapeutic alternative in patients who are not candidates for surgery, with excellent rates of recovery for non-advanced stages of illness. The use of innovative 3D conformational and intensity-modulated radiotherapy methods has also significantly reduced the risk of post-treatment complications for the patient. The other therapeutic alternatives offered, retain a role within the various possible clinical scenarios and for this reason, the management of the patient with prostatic neoplasia is often multidisciplinary.

  • Kidney Tumour

In 2016, Professor Francesco Montorsi and Dr. Umberto Capitanio, from the Department of Urology of the San Raffaele Hospital, have signed a review article on kidney cancer, published in the prestigious magazine scientific ‘Lancet’. The article takes focus on the incidence of the disease at a global level, the most advanced diagnosis and therapy techniques, and the future of research in this pathology, in which the San Raffaele Hospital is an international leader.

There are different types of kidney cancer, each with specific histopathological and genetic characteristics. The use of diagnostic investigations has allowed a more frequent and early diagnosis of renal neoplasms (tumours of smaller size). The traditional approach in the diagnosis of renal neoplasms is related to the use of ultrasound, CT or magnetic resonance. Bone scintigraphy is a diagnostic investigation that provides information about possible bone involvement (skeletal metastases) and is indicated in patients with bone pain or to complete the staging of the disease in particular cases. The treatment of choice of localized renal tumour is the surgical procedure that guarantees the best results in terms of oncological radicality. However, advanced or metastatic renal cancer is also good for surgical treatment when associated with a multidisciplinary approach: the removal of the main tumour (debulking), in fact, improves the response to anti-angiogenic treatment.

  • Bladder Tumour

Being in most cases of a urothelial disease, the tumour can also be localized in the upper excretory apparatus through an ultrasonography of the urinary tract. The therapeutic approach varies radically according to the neoplastic infiltration and, for this reason, it always distinguishes itself in non-invasive muscle tumour and invasive muscle tumour.

  • Testicular Tumour

Testicular cancer is a relatively rare disease. There are different histologic forms, with significant prevalence of germ cell-defined tumours compared to defined tumours of stromal origin. Germinal testicular tumours are then subdivided into seminomatous or nonseminomatous, histological classification that is of great importance in therapeutic terms. The staging of the testicular tumour, that is the determination of its characteristics and its extension, occurs through: 1) the blood dosage of some specific and sensitive tumour markers; 2) inguinal orchiectomy, which allows the removal of the primary tumour and histological evaluation; 3) the execution of a thorax-abdomen CT scan, in order to be able to identify the presence of any secondary lymph node localization or of other organs. In fact, the testicular tumour cells are characterized by a rapid growth that involves a high risk of early secondary dissemination. Histology and the stage of the tumour (testicular localization, involvement of retroperitoneal lymph nodes or metastases in other locations) determine the therapeutic course following orchiectomy (radiotherapy, chemotherapy or removal of retroperitoneal lymph nodes) and subsequent follow-up.

  • Penile Tumour

The penile cancer is a rare squamous cell carcinoma that originates in the epithelium of the foreskin and the glands. Malignant melanomas of the penis and basal cell carcinomas are much rarer. Pre-malignant lesions are subdivided into those less frequently associated with subsequent tumour development and those more frequently associated with it. The diagnosis of Penile tumours is based primarily on a thorough examination of the external genitalia, aimed at verifying and evaluating in detail the lesion(s) and its morphology. It is therefore necessary to have a biopsy sampling of the lesion in order to have the histological certainty of the type, and to be able to continue with the most appropriate treatment. The treatment ranges from minimal surgical resections of the disease (which can also be performed with alternative techniques such as laser therapy, cryotherapy) with increasing resections, such as glandulectomy, partial penile amputation) and total. In the case of a further invasive disease, the therapy involves a neoadjuvant chemotherapy and, in the responsive patients, a subsequent surgery. In advanced and metastatic diseases, the therapy is palliative chemotherapy. Radiation therapy is both a possible alternative for limited injuries and a further palliative possibility.

Main Pathologies Treated:

  • Prostate tumour
  • Kidney tumour
  • Bladder tumour
  • Testicular tumour
  • Penile tumour

Top Procedures:

  • Prostate tumour
    • Radical surgical prostatectomy
    • Robotic-assisted root prostatectomy (with Da Vinci® system)
    • Pelvic and retroperitoneal lymphadenectomy
    • Brachytherapy
  • Kidney tumour
    • Renal tumourectomy or surgical and / or laparoscopic and / or robotic radical nephrectomy (DaVinci System®)
    • Cytoreductive nephrectomy with possible caval thrombectomy
    • Cryotherapy
    • Radiofrequency
  • Bladder tumour
    • Endoscopic trans-urethral resection (with possible Hexvix®)
    • Intravesical chemotherapy
    • Radical cystectomy with orthotopic (e.g. neovescica) and heterotopic urinary derivations
    • Radical cystectomy with ureterocutaneostomy
    • Hyperthermia and chemotherapy (Synergo® system)
  • Testis tumour
    • Orchiectomy with or without testicular prosthesis
    • Retroperitoneal lymphadenectomy
  • Penile tumour
    • Penile biopsy
    • Penile amputation or penectomy
    • Inguinal lymphadenectomy

Non-Oncological Pathologies

  • Prostatic Hypertrophy

Benign prostatic hypertrophy is a very common pathology in the male population. It is defined as the growth of prostate tissue in the periurethral area (prostatic adenoma), creating problems with urination over time. An accurate clinical examination, also including rectal exploration, is important to rule out any other pathologies that can give a superimposable symptomatology. The treatment of Prostatic Hypertrophy uses various therapeutic tools, with the aim of improving the patient's symptomatology, its quality of life and avoiding long-term complications ranging from urinary retention, bladder stones and chronic renal failure. The first therapeutic approach is usually pharmacological. In case of ineffective drug therapy, there are several surgical options for BPH, all aimed at resolving the obstruction of urine through the removal of prostatic adenoma, responsible for the obstruction itself. We pass from endoscopic interventions such as Trans-Urethral Endoscopic Prostate Resection to open surgery, such as Trans-Bladder prostatic adenectomy, the latter necessary in the case of large prostate. Currently, a surgical technique is also available that allows the removal of prostatic adenoma by endoscopy, even in the case of large size. This technique uses the "Holmium laser" and is called Enucleation of the Prostate with Holmium Laser.

The therapeutic strategy to be implemented will therefore be based on the degree of severity of the patient's symptomatology and the consequent impact on his daily life, discussing the possible risks and benefits of the clinical pathway.

  • Kidney, Ureteral, and Bladder Stones

Kidney, Ureteral, and Bladder stones is one of the pathological conditions that most frequently afflicts the urinary tract. It involves the formation of aggregates of minerals and organic substances which, once precipitated, can obstruct the excretory pathways. Depending on the location of the stone, its size and its chemical composition, the characteristics of the patient, different therapeutic options are possible (sometimes also in connection) ranging from expulsive medical therapy, to therapy through agents that dissolve the stone, observation and monitoring, up to active removal through more or less invasive procedures.

  • Neurological Bladder

The neurological bladder is a neurological dysfunction of the lower urinary system. Patients with severe neurological deficits suffer from incontinence or cannot urinate. To establish possible nerve damage, it is important to undergo a neuro-urological examination including inspection and palpation of the abdomen, inguinal region, external genitalia, rectal and pelvic evaluation. This examination, however, cannot always be conducted completely in patients suffering from serious neurological diseases (eg spinal trauma, Parkinson's disease or multiple sclerosis). In such cases alternative examinations are offered such as urinalysis and urinalysis to evaluate a possible urinary infection that can worsen the symptoms of incontinence; blood tests for renal failure risk; X-ray examinations of the upper urinary route to identify structural anomalies; cystoscopy is indicated for specific abnormalities such as haematuria; urodynamic examination, to study neurological changes and to measure the pathological and physiological factors involved in the accumulation, transport and elimination of urine.

  • Male Infertility

Many couples have more than one reason of infertility, while in some cases it is not possible to identify the cause. Diagnosis and treatment may require investigations such as an anamnesis and objective examination; spermiogram to evaluate the volume of ejaculation, the number of spermatozoa, the normality of the forms, the vitality, the motility; scrotal ultrasound for a structural evaluation of epididymis, and in particular for the diagnosis of varicoceles; hormonal dosages for the evaluation of the functioning of the hypothalamus-hypophysis-testicles axis; urine culture and sperm culture, with particular attention to pathogens that can affect the quality of sperm cells, and therefore the reproductive capacity; genetic tests are also required to evaluate the existence of mutations of the Y chromosome or of the CFTR locus, which predispose to infertility.

  • Erectile Dysfunction

Regarding the diagnosis of Erectile Dysfunction, the first step is the urological examination during which the specialist can collect detailed information on the medical, psychological and sexual history of the patient; the patients then fills out a set of questionnaires provided by the physician and validated in scientific literature (the International Index of Erectile Dysfunction questionnaire) that allow in a simple and quick way to have an objective idea of the severity of the Erectile Dysfunction, where present. The second step is the urological examination that can highlight any alterations to the external genitalia and the prostate. The third diagnostic aspect is represented by laboratory tests, decided ad hoc by the specialist on the basis of the type of patient, which basically includes the evaluation of the glycaemic values, the lipid profile, and the hormonal framework. The first line of treatment is eliminating the cause, when possible, and any modifiable risk factors (e.g. smoking). Exception is made for the psychogenic, post-traumatic and hormonal arteriogenic Erectile Dysfunction that can be effectively treated with specific treatment, in other cases the Erectile Dysfunction is not cured but treated.

  • Urinary Incontinence

Urinary incontinence can be divided into stress incontinence which is characterized as an involuntary loss of small amounts of urine that occurs under stress when the pressure on the bladder increases, and the overactive bladder, which is caused by involuntary contractions of the detrusor muscle. The overactive bladder in turn is subdivided into: idiopathic, neurogenic, mixed incontinence, regurgitation incontinence occurring when the bladder fills over its capacity and fails to empty completely, and nocturnal enuresis. Diagnosis is based initially on medical history and physical examination. Secondly, instrumental diagnostic tests must be performed. The therapy of urinary incontinence includes the use of symptomatic devices, lifestyle and exercise, pelvic rehabilitation, drug therapy varies depending on the cause that gave rise to the incontinence, and surgical interventions. In the most severe cases a cystoplasty (bladder augmentation) or an external derivation (urostomy) or internal urine may be performed.

Main Pathologies Treated:

  • Prostatic Hypertrophy
  • Prostatitis
  • Cystitis
  • Kidney, ureteral and bladder stones
  • Urethral and ureteral strictures
  • Pyeloureteral joint syndrome
  • Urinary incontinence
  • Neurological bladder
  • Paediatric urological disorders
  • Male infertility
  • Erectile dysfunction
  • Urinary Incontinence

Top Procedures:

  • Prostatic Hypertrophy
    • Transurethral resection of prostatic adenoma (TURP)
    • Prostatic enucleation with Holmium laser (HoLEP)
    • Adenomectomy and trans-bladder diverticulectomy with litholopaxy
  • Renal and ureteral stones
    • Ureterorenoscopy with lithotripsy
    • Extracorporeal lithotripsy (ESWL)
    • Nephrolithotomy
  •  Neurological bladder
    • Botulinum toxin injection
  • Male Infertility
    • Varicocelectomy by inguinal or sub groin
    • Testicular Sperm Extraction (TESE)
    • Microsurgical suction of epididymal sperm (MESA)
  • Erectile Dysfunction
    • Positioning of penile prostheses
    • Intra-cavernous pharmacotherapy injections
  • Urinary Incontinence
    • Surgery for male urinary incontinence

 

NOTABLE ADVANCED TECHNOLOGICAL EQUIPMENT:

  • 2 robotic systems Xi Da Vinci dedicated to urological surgery
  • 3D laparoscopy
  • Dedicated MRI fusion biopsy

 

NOTE

1Academic Ranking Score: A Publication-Based Reproducible Metric of Thought Leadership in Urology. Eur Urol. 2012 Mar; 61(3):435-9.