Surgical Innovation
Surgical techniques
Surgical techniques described by Dr. Calarco and colleagues at congresses and in scientific journals, with their references. Study results concern selected groups of patients and are not a guarantee of outcome for the individual patient.
- 2021Active Guidewire
Active guidewire technique for the endoscopic treatment of ureteral stones, compared with the standard technique in a single-centre comparative study (Cristo Re Hospital, Rome) of 100 semirigid ureteroscopies: in 50 cases a thin ureteral catheter was used as an "active guide" instead of the traditional guidewire, in 50 the standard technique. In the study, with the active guide operating times (relative to stone volume) were about 39% shorter and peri-operative infections were 3% versus 30% with the standard technique; these are single-centre results and cannot be transferred automatically to an individual patient. Source: Calarco A, Frisenda M, Molinaro E, Lenci N. The active guidewire technique versus standard technique as different way to approach ureteral endoscopic stone treatment. Arch Ital Urol Androl. 2021;93(4):431-435. doi: 10.4081/aiua.2021.4.431. PMID 34933539.
- Low-energy bipolar enucleation of the prostate (Low Energy BIPOLEP)
Endoscopic enucleation of the prostatic adenoma with a bipolar resectoscope. The tissue is detached mainly by blunt dissection along the anatomical planes and only minimally with energy (hence "low energy"); it is then removed by morcellation. The aim is to reduce thermal effects on tissue and, where possible, preserve ejaculation; continence and ejaculation outcomes vary from patient to patient. Dr. Calarco has performed it for about ten years; today BIPOLEP is giving more room to HoLEP, performed with the holmium laser.
- 2025ZANCLE
ZANCLE ("Z" Anatomical Needle Cut Leads Ejaculation): unilateral endoscopic "Z"-shaped incision of the bladder neck and prostate for primary bladder neck obstruction, with the aim of preserving ejaculation. Described in three studies: Urologia Journal 2025 (PMID 40243909), Surgeries 2026 (doi:10.3390/surgeries7030084; 186 patients with follow-up of up to 24 months) and Journal of Clinical Medicine 2026 (PMID 42882160).
- 2025RASP (Robot Assisted Simple Prostatectomy) with San Carlo Flap
Robot-assisted simple prostatectomy with the Da Vinci Xi system for very large prostates, performed at San Carlo di Nancy Hospital; the San Carlo Flap option preserves a strip of the mucosa lining the urethra, used as a new sphincter (neosphincter) to keep ejaculation directed outwards (antegrade). The study has been accepted for publication; the reference and DOI will be added as soon as the article is online.
RASP (Robot Assisted Simple Prostatectomy) with San Carlo Flap
Short answer. RASP (Robot Assisted Simple Prostatectomy) is a procedure for a very large enlarged prostate (benign prostatic hyperplasia): with the Da Vinci Xi robot, the part of the prostate that blocks the passage of urine (the adenoma) is removed. Dr. Alessandro Calarco has described the “San Carlo Flap” option, which preserves a strip of the mucosa lining the urethra with the aim of maintaining ejaculation. The study that describes it has been accepted for publication in a scientific journal; the bibliographic reference and DOI will be added to this page as soon as the article is online.
Very large prostate: why it causes symptoms
With age the central part of the prostate can become very enlarged and compress the urethra. The result is a weak stream, a need to urinate often including at night (nocturia), difficulty starting, a feeling of incomplete emptying and, in advanced cases, being unable to urinate (urinary retention).
Who it may be offered to
RASP is indicated for very large prostates, when urinary symptoms do not improve enough with medication or complications of the enlarged prostate arise. As with any prostate procedure, the indication is set only after the consultation and tests (PSA, ultrasound, uroflowmetry with post-void residual urine and, if necessary, other tests).
How it is performed
The procedure is performed with the Da Vinci Xi robotic system, under general anaesthesia, through a few small incisions in the abdomen. The surgeon removes the adenoma, that is, the part of the prostate that blocks the passage of urine, and sends it for histological examination.
San Carlo Flap option: during the procedure a strip of the mucosa lining the urethra is preserved and used as a new sphincter (neosphincter): its purpose is to help semen leave the body (antegrade ejaculation) instead of going into the bladder.
At the end a catheter is placed, which generally stays in for 3 days. The hospital stay is usually 3 days.
Possible side effects and risks
As with any surgical procedure on the prostate performed through the abdomen with the robot, the following are possible:
- risks of general anaesthesia and of the position required for the procedure;
- bleeding, which rarely may require a transfusion;
- blood in the urine and burning on urination in the first weeks;
- urinary tract or wound infection;
- urinary leakage in the first weeks, usually temporary;
- retrograde ejaculation or reduced ejaculate volume: the technique is designed to reduce this risk but cannot rule it out;
- urine leaking from the internal suture, which may require the catheter to be kept in for longer;
- later on: narrowing of the bladder neck or urethra;
- rarely: injury to nearby organs, venous thrombosis, hernia at the site of the incisions or the need to convert the procedure to open surgery.
Risks and alternatives (medication, endoscopic enucleation, other techniques) are discussed at the consultation and set out in the informed consent.
What the data show
In the study on the San Carlo Flap option, accepted for publication and not yet available online, about 70% of patients kept ejaculation. This is a group of selected patients: the figure cannot be transferred automatically to an individual case and is not a guarantee of outcome. As with any new technique, further studies are needed.
Where it is performed
Dr. Alessandro Calarco performs RASP at San Carlo di Nancy Hospital, Via Aurelia 275, Rome, where the procedure has been available since 2025, privately, under agreement with insurers or through the Italian National Health Service (SSN). Consultations by appointment are also available at Nostra Signora della Mercede Clinic and at the practice in Viale Aventino 38, Rome. Bookings: +39 366 6856844.
Frequently asked questions
Sources
- European Association of Urology (EAU). Guidelines on the Management of Non-neurogenic Male LUTS, current edition (section on simple prostatectomy).
- Study on RASP with San Carlo Flap accepted for publication: bibliographic reference and DOI will be added after online publication.
Robotic radical prostatectomy
Indications, pathway, continence and erection, risks: Robotic prostate surgery in Rome.
Other procedures
Other procedures performed
Other minimally invasive and endoscopic procedures performed by Dr. Calarco.
- RIRS — Retrograde Intrarenal Surgery
Flexible endoscopic technique reaching the kidney through the natural urinary tract with digital instruments. Discharge usually within 24 hours, depending on recovery.
- mini-PCNL — Percutaneous Nephrolithotomy
Small-calibre percutaneous access to the kidney to remove large or complex stones, including staghorn stones. The indication depends on stone size, location and density and is set at the consultation.
- HoLEP — Holmium Laser Enucleation of the Prostate
Endoscopic enucleation of the prostate with a holmium laser, indicated by the EAU guidelines as an option for medium and large prostates; the risk of bleeding is generally low.
- Da Vinci Xi Robotic Surgery
Da Vinci Xi system: four robotic arms, 7 degrees of freedom, 10× 3D vision, tremor filter.
- Microsurgical Varicocelectomy
Microsurgical correction of varicocele for treatment of male infertility and chronic testicular pain. Subinguinal technique.
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