INTRODUCTION
The first successful kidney transplant between identical twins, performed by Joseph Murray in 1954, marked the beginning of the modern era of solid organ transplantation, demonstrating that graft failure was primarily due to immune rejection rather than technical limitations. Murray, together with Thomas, a hematologist who pioneered bone marrow transplantation, was awarded the Nobel Prize in Physiology or Medicine in 1990, becoming the last practicing clinical physician to receive this honor in that category 1. Within a decade, postoperative outcomes for kidney transplants between genetically non-identical individuals improved with the introduction of azathioprine, actinomycin D, and prednisolone. The subsequent development of additional immunosuppressive agents, particularly cyclosporine, further enhanced transplant success. Advances in the basic sciences, including biology, immunology, complement-dependent crossmatching, and pharmacology, were instrumental in establishing organ transplantation as a feasible clinical practice. Over the past decade, innovations in organ perfusion devices and preservation solutions have extended the functional viability of ex vivo organs from cadaveric donors, while robotic-assisted surgery has recently refined operative techniques 2.
In Italy, organ transplantation emerged relatively late. The legal framework began with Law No. 235/57, regulating organ donation from cadaveric donors, followed by Law No. 458/67, addressing kidney donation from living donors, and Law No. 519/68, concerning the determination of brain death. These laws established the foundational legal procedures for transplantation. Two decades later, Law No. 578/88 on death verification further refined the legal processes governing organ donation.
This review traces the history of organ transplantation in Italy from its inception. A central thesis emerges from this history: the Italian experience is characterized by clinical innovation that frequently preceded legal regulation, regional autonomy that gradually evolved into national coordination, and a persistent commitment to living donation despite cultural and bureaucratic obstacles. Further details on the development of the transplant system in Italy and the application of new technologies are provided in two additional reports included in this issue of the European Journal of Transplantation.
METHODS
Historical information was gathered through a systematic review of Italian and international medical literature from 1950 to 2025 using PubMed, Scopus, and archival searches of Italian surgical journals including Il Policlinico, Bollettino Medico Chirurgico Pisano, and Minerva Chirurgica. Additional sources included institutional records from major transplant centers, personal communications with surviving pioneers and eyewitnesses (listed in the Acknowledgements), and legal documents from the Italian Parliament and Ministry of Health. Where discrepancies between sources existed, priority was given to contemporaneous published reports; when none were available, the earliest published retrospective account corroborated by multiple sources was used. The manuscript focuses on publicly documented procedures and does not claim to capture every individual transplant performed.
THE BEGINNING OF TRANSPLANTATION IN ITALY
The development of organ transplantation in Italy was characterized by significant legal and regulatory challenges. While kidney transplantation had already been performed internationally with increasing success, Italian clinicians faced both legislative gaps and societal scrutiny in establishing this complex practice.
The first organ procurement from a cadaveric donor in Italy was performed by Paride Stefanini and his team of Sapienza, University of Rome. In the absence of clear legal guidance, the team was subsequently accused of first-degree murder. At the time, Law 235/57 theoretically permitted cadaveric organ donation, but no implementing decrees or practical procedures had been issued. Furthermore, authorization for the graft procurement had been granted only verbally by the Public Prosecutor, leaving the team in a legally precarious position. This legal uncertainty highlighted the urgent need for formal regulations, leading to the enactment of Law 519/68, which established criteria for the determination of brain death, and later Law 644/75, which regulated graft procurement from deceased donors for therapeutic transplantation, effectively updating the framework provided by Law 235/57.
For living donation, the first clinical transplant also preceded the legislation regulating this practice. In fact, Law 458/67 was enacted only after the first successful kidney transplant from a living donor, which was performed, once again, by Prof. Paride Stefanini in 1966. However, the implementing decrees for this law were not issued until the early 2000s, after the case of Irene Vella, who donated a kidney to her husband in Pisa on February 6, 2003, but was initially denied official recognition of her medical condition, specifically, recognition as a living donor for insurance and employment leave purposes, drew national attention when she appeared on the Maurizio Costanzo Show (February 14, 2003).
These early experiences illustrate the intertwined evolution of medicine, law, and society in Italy. Within this historical framework, the pioneering efforts of Raffaello Cortesini, supported and encouraged by his mentor Paride Stefanini, played a foundational role. His contribution extended beyond technical surgical achievements, encompassing ethical clarification, institutional development, and national coordination. By demonstrating the clinical feasibility and moral legitimacy of living donation, supporting the adoption of neurologic criteria for death determination, and promoting integrated transplant networks, he helped guide Italian transplantation from an experimental endeavor to a regulated and sustainable medical discipline. Available records indicate broad consensus around Cortesini’s leadership role, although the competitive environment of Italian surgery in the 1970s1980s also saw important contributions from other centers, as detailed later.
The efforts of clinicians, coupled with incremental legal reforms, laid the foundation for a structured, ethically sound, and legally protected transplantation program. They also demonstrate how early clinical innovations often precede regulatory frameworks, with public discourse and landmark cases acting as catalysts for legal and policy development.
As evidence of the level reached by Italian transplant medicine, the World Transplant Congress was held in Rome in 2000, chaired by Raffaello Cortesini. The event was a great success in terms of both the number and the quality of participants, including Pope Saint John Paul II, who took the stage at the Palazzo dei Congressi to express his support for the work of transplant surgeons (Fig. 1)). Subsequently, Italy hosted other major international transplantation congresses, including meetings of the European Society for Organ Transplantation (ESOT), held in Venice in 2003 and in Milan in 2021 (Presidents: Umberto Cillo and Luciano Potena), as well as congresses of the International Pancreas and Islet Transplant Association (IPITA), held in Milan (1997), Venice (2009), and Pisa (2025; Presidents: Ugo Boggi, Lorenzo Piemonti, and Fabio Vistoli).
Despite the legislative gaps and organizational challenges that characterized the early phase of organ transplantation in Italy, it is important to emphasize that enthusiasm and engagement within the medical community were strong from the outset. Indeed, only two months after the first transplants performed in early May, the Italian Society for Organ Transplantation (Società Italiana dei Trapianti d’Organo, SITO; later renamed the Italian Society for Organ and Tissue Transplantation and Regenerative Medicine) was founded in July 1966.
SITO was established on the initiative of Profs. Paride Stefanini and Raffaello Cortesini, who convened a group of 29 physicians on a summer afternoon in July 1966 in the lecture hall of the Second Surgical Clinic at the Policlinico Umberto I in Rome. Among the participants were prominent figures such as Pietro Valdoni, Ruggero Ceppellini, Ulrico Bracci, Gioacchino Nicolosi, Ettore Ruggieri, Piero Confortini, Piero Mazzoni, Beniamino Tesauro, and Carlo Umberto Casciani. The aims of the Society were concisely defined in Article 2 of its Statute: “SITO is a non-profit organization whose purpose is to promote knowledge and the clinical application of organ and tissue transplantation".
The first SITO Congress was held in Rome in September 1967. It was a small meeting of pioneers who believed in the future of transplantation, addressing key topics such as organ preservation, histocompatibility, and anti-rejection therapy. Among the participants were two leading figures in international transplantation, Jean Hamburger and Rudolf Pichlmayr. The subsequent congress, held in Sanremo in 1968, represented a pivotal moment in Italian transplantation history. Discussions focused on the Harvard criteria for the definition of brain death, leading to the drafting of the “Sanremo Charter”, which established clinical parameters for the diagnosis of irreversible brain injury in patients admitted to intensive care units.
Following this meeting, SITO actively promoted parliamentary and legal initiatives that, after years of debate, culminated in Law No. 644 of December 2, 1975, which for the first time formally defined the criteria for brain death in Italy.
Over the years, SITO has been led by numerous distinguished presidents, including Paride Stefanini (Rome), Edmondo Malan (Milan), Piero Confortini (Verona), Girolamo Sirchia (Milan), Carlo Umberto Casciani (Rome), Raffaello Cortesini (Rome), Antonio Vegeto (Milan), Franco Mosca (Pisa), Davide D’Amico (Padua), Antonio Famulari (L’Aquila), Pasquale Bartolomeo Berloco (Rome), Franco Citterio (Rome), Umberto Cillo (Padua), and Ugo Boggi (Pisa). The current president is Luciano Gregorio De Carlis (Niguarda Hospital, Milan).
Another milestone in the history of SITO, and therefore of the Italian transplant community, was the establishment in 2022 by the then President of the Society (Ugo Boggi) of its official journal, the European Journal of Transplantation, which hosts this special issue dedicated to the history of transplantation in Italy. The first issue of the European Journal of Transplantation was published in April 2023.
KIDNEY TRANSPLANTATION
Italy’s first kidney transplant program was established in 1961 at the Second Surgical Clinic of Sapienza University of Rome, Policlinico Umberto I in Rome. The Director of the Clinic was Prof. Paride Stefanini (Fig. 2), assisted by Profs. Cortesini, Baroni, Arullani, Boffo, Casciani, and Cucchiara. As a first step, in October 1961, the group was prepared to initiate hemodialysis in patients with chronic uremia. In early 1966, after an intensive five-year preparatory period, Prof. Casciani developed an organ preservation solution composed of magnesium, bicarbonates, and other salts. In parallel, the surgical technique was refined by Prof. Stefanini, who had previously performed experimental kidney transplants in dogs and chimpanzees (1963), and later in human cadavers at San Giovanni Hospital, with particular attention to vascular variations.
On May 2, 1966, Prof. Pietro Valdoni, Director of the First Surgical Clinic of Sapienza University of Rome, Policlinico Umberto I in Rome, perfomed the first clinical kidney transplantation in Italy. The graft was obtained from a deceased donor. Unfortunately, the recipient died intraoperatively.
The following day, on May 3, 1966, Prof. Stefanini performed the first successful clinical kidney transplantation in Italy. His first assistant was Prof. Raffaello Cortesini, and the second assistant was Prof. Carlo Umberto Casciani. The recipient was a 17-year-old female patient with chronic glomerulonephritis. The kidney was procured at San Salvatore Hospital in L’Aquila, approximately 100 km from Rome, from a living donor. The kidney, located in the right iliac fossa with both vessels originating from the iliac axis, was removed from a 29-year-old female donor for clinical reasons. The nephrectomy was performed by Prof. Giorgio Ribotta, assisted by Drs. Arullani and Casciani (Figs. 3-4). After retrieval, the graft was flushed, cooled, and rapidly transported to Rome in a portable container. At the time (1966), no highway connected Rome and L’Aquila; therefore, police escorted the organ by car across the Apennines via the Via Salaria. The journey required approximately two and a half hours instead of the usual minimum of three hours and 40 minutes. The experimental work previously performed on cadavers at San Giovanni Hospital proved extremely useful, as the graft presented vascular variations. The transplant procedure was successfully completed in the late afternoon. Postoperatively, the patient received azathioprine and corticosteroids as immunosuppressive therapy and survived six months with a functioning graft 3.
Some days later, on May 8, 1966, the first xenotransplantation in Italy was performed (Fig. 5). Although xenotransplantation represented one of the earliest attempts in the history of renal transplantation, with the first cases dating back to 1906, the experience led by Prof. Stefanini was second only to the small series reported by Reemtsma (six cases) performed in Saint Louis (USA) between 1963 and 1964, in what can be considered a “modern” era compared with the very early pioneering attempts, which occurred at a time when immunosuppressive drugs, anesthesia, and surgical techniques were still largely undeveloped 4. In the Roman case, the donor was a 20-year-old chimpanzee named Peppone, originating from the Rome Zoo. Peppone was not sacrificed and survived the nephrectomy, subsequently returning to the zoo. The recipient was a 19-year-old male patient from Sardinia. Postoperatively, the patient received azathioprine, actinomycin C, and corticosteroids as immunosuppressive therapy. Unfortunately, he survived only 31 days, dying from complications of a gastric ulcer, in an era when immunosuppression was primarily corticosteroid-based and gastroprotective agents were not available. The xenotransplantation program was subsequently discontinued due to the high costs associated with animal maintenance. Following the approval of Law No. 458/1967, the first living-related kidney transplantation was performed again by Prof. Paride Stefanini in 1967 between two sisters.
The impact of Prof. Stefanini’s pioneering xenotransplantation was worldwide. At that time, Prof. Eugenio Santoro was in Paris at the Hôpital Bouscicaut. He recalls that Prof. Stefanini had been invited to Paris by Prof. Fontaine to attend a vascular surgery congress. The event had already received significant media coverage, particularly in France-Soir. When Prof. Stefanini entered the congress hall, Prof. Fontaine, who was chairing the session, interrupted the proceedings, stood up to greet him, and reminded the audience of the extraordinary transplantation he had performed only a few days earlier. The hall then erupted in a prolonged standing ovation.
The pioneering kidney transplant activity at Policlinico Umberto I continued in the following years, with the first series of 15 kidney transplants, 9 from living donors and 6 from deceased donors, reported by Profs. Casciani and Cortesini in 1969 at the First National Congress of the Italian Society of Nephrology and Urology.
Unfortunately, in 1969, the transplant activity at Policlinico Umberto I was abruptly interrupted due to a judicial investigation concerning organ retrieval from a deceased donor after brain death. Brain death was determined according to protocols adopted in other European countries and recognized by the Sydney Declaration, although it was not yet accepted by the Italian legal system. The trial concluded in 1971 with a dismissal verdict, allowing the program to resume. Subsequently, Prof. Cortesini conducted extensive research in kidney transplantation over several years. After Prof. Cortesini’s retirement and the premature death of Dario Alfani, a talented and visionary surgeon, the transplant program at Policlinico Umberto I was successively led by Prof. Pasquale Berloco and Prof. Massimo Rossi.
The first successful allotransplants in Rome soon inspired other kidney transplant programs in Bologna, Verona, Milan, and Pavia during the 1960s.
On October 24, 1967, at Bologna Polyclinic, Aldo Martelli, in collaboration with Alberto Reggiani, Roberto Rusconi, and nephrologist Vittorio Bonomini, performed a cadaveric kidney transplant in a 34-year-old patient with chronic kidney disease and uremia. Postoperative immunosuppressive therapy included corticosteroids, actinomycin, and azathioprine. Seventeen kidney transplants were subsequently performed, predominantly using living donors. Institutional and legal obstacles limited transplantation activity for five years, primarily restricting the program to cadaveric donors. This challenge was eventually overcome through the efforts of Gerardo Martinelli and Leonardo Possati, in collaboration with Vittorio Bonomini. The number of transplants increased steadily from 1975 to 2010, during which over 1,800 kidney transplants were performed by a surgical team including Alessandro Faenza, Giovanni Fuga, and Bruno Nardo, in collaboration with Bonomini. In 2011, the program was continued by Antonio Daniele Pinna and colleagues, together with consultant nephrologist Sergio Stefoni. Today, the kidney transplant program at Bologna S. Orsola Polyclinic is led by Matteo Ravaioli and Gaetano La Manna.
In November 1968, Pietro Confortini and Giusto Ancona performed the first kidney transplantation at the Verona Polyclinic. A cadaveric kidney was transplanted into a young adult patient receiving hemodialysis. Ten kidney transplants were performed over the following three years, and a further 41 transplants in the subsequent two years, including kidneys from living donors. The kidney transplant program at the Verona Polyclinic has continued under the leadership of Giusto Ancona, followed by Luigino Boschiero, and is currently led by Alessandro Antonelli, with more than 2,500 kidney transplants performed to date.
The first cadaveric kidney transplantation at the Milano Polyclinic was performed in May 1969 by Edmondo Malan, Ugo Ruberti, and Antonio Vegeto, in collaboration with nephrologist Filippo Quarto di Palo and immunologist Domenico Mazzei. The recipient was a 25-year-old man who had been on hemodialysis for three months, while the donor was a 31-year-old woman who had died of a cerebral hemorrhage secondary to spontaneous aneurysmal rupture. Postoperative immunosuppression consisted of corticosteroids, azathioprine, and antilymphocyte globulins. In the following years, the program expanded under the leadership of Edmondo Malan, Ugo Ruberti, Edoardo Lasio, Enrico Pisani, and Mariano Milost della Grazia, in collaboration with nephrologist Claudio Ponticelli, who made seminal contributions to kidney transplantation through his pioneering work in transplant immunology, the optimization of immunosuppressive therapy, and the clinical management of graft rejection and transplant-related glomerular diseases. Cadaveric kidney transplants were performed in the Zonda Pavilion, whereas living-donor transplantations were carried out in the Riva-Croff Pavilions. Over the subsequent three years, 110 kidney transplants were performed. Later surgical leadership included Antonio Vegeto and Luisa Berardinelli, in collaboration with Caludio Ponticelli and Piergiorgio Messa. Notably, in the 1970s, Luisa Berardinelli was the first female surgeon in Italy to perform a solid-organ transplant (a kidney transplantation). By 2015, the center was led by Mariano Ferraresso and, more recently, in collaboration with nephrologist Giuseppe Castellano.
In 1969, Giuseppe Salvatore Donati initiated kidney transplantation at the San Matteo Polyclinic in Pavia, performing five transplants between June 1969 and January 1970. However, the absence of a formal institutional program led to the suspension of further activity. Kidney transplantation was resumed only three decades later, under the initiative of nephrologist Antonio Dal Canton.
Although the first donation after circulatory death in Italy occurred in Pisa in 2005, resulting in an unsuccessful liver transplantation, the first successful kidney transplantation from a donation after circulatory death was performed in Pavia in 2008 by Massimo Abelli.
In the 1970s, kidney transplant programs were established in several additional Italian cities under the leadership of general surgeons, including Giancarlo Castiglioni (Policlinico Agostino Gemelli, Rome, 1970), Mario Selli (Pisa, 1972), Lino Belli (Milan-Niguarda, 1972), Giuseppe Marinaccio and Francesco Paolo Selvaggi (Bari, 1973), Pier Giuseppe Cevese (Padua, 1974), and Leonardo Loiacono (Brescia, 1979).
In these early experiences, it is important to highlight the role of nephrology, a discipline that, during the 1960s and 1970s, was emerging as an autonomous field distinct from internal medicine, within which it had originally developed. Gabriele Monasterio (1903-1972) is universally regarded as the father of Italian nephrology. Although he died (3 January 1972) just a few days before the first kidney transplant performed in Pisa (15 February 1972), he left behind a strong and well-established school, primarily represented by Sergio Giovannetti and Quirino Maggiore. As a result, Pisa was among the first centers in Italy to initiate a renal transplantation program. The availability in Pisa of a highly developed nephrology unit, arguably the leading nephrology center in Italy at that time, together with a high-level surgical team (Prof. Selli, one of the earliest pupils of Prof. Stefanini, had moved to Pisa from Perugia to work alongside him), constituted the essential foundation for launching a kidney transplant program. While this may appear self-evident today, at that time it was exceptional and clearly indicative of a center of excellence in healthcare. The centers that first initiated kidney transplantation programs likely benefited from similar foundations, which, from the outset, emphasized the inherently multidisciplinary nature of transplantation.
A notable historical event in the 1970s involved the presentation of successful transplant procedures at the 77th Congress of the Italian Society of Internal Medicine and the 38th Congress of the Italian Society of Surgery (October 1976). Concurrently, Piero Confortini promoted interregional collaboration between Veneto and Lombardy, later joined by Province of Trento, Friuli-Venezia Giulia, Liguria, Umbria and Marche, forming the North Italy Transplant Program (NITp). This initiative facilitated the establishment of an interregional center for donor-recipient typing and equitable kidney distribution, later expanding to other organs. Leadership of the program has included Girolamo Sirchia (who served also as Ministry of Health), Mario Scalamogna, Tullia Maria De Feo, Giuseppe Piccolo and Massimo Cardillo.
A few years later, with the aim of increasing organ procurement and transplantation activities even in regions that were not part of the NIT (Nord Italia Transplant), the AIRT (Associazione Interregionale Trapianti) was founded, bringing together Piedmont, Valle d’Aosta, Toscana, Puglia, Emilia-Romagna, and Autonomous Province of Bolzano and the OCST (Organizzazione Centro-Sud Trapianti), which included Abruzzo, Lazio, Campania, Basilicata, Calabria, Sardinia, Sicily, and the transplant center of Malta. To encourage procurement activities, particularly in central and southern Italy, regional transplant centers were established to enable local transplantation of the organs retrieved, even by pushing through the necessary authorizations. This was the case in March 1989 in Reggio Calabria, where, with the collaboration of physicians from the Policlinico Umberto I in Rome, the first kidney transplant in Calabria was performed.
In 1981, the vascular surgeons Roberto Ferrero and Piero Bretto, the urologist Giorgio Sessa, and the nephrologists Antonio Vercellone and Giuseppe Paolo Segoloni initiated a kidney transplant program in Turin. This center, subsequently named after A. Vercellone, rapidly expanded and, within a few years, became the leading program in Italy in terms of activity volume, reaching 4,000 kidney transplants in 2021, together with the highest rate of patient complexity and an older median donor/recipient age, according to data provided by the Centro Nazionale Trapianti (CNT) (“Quality evaluation of kidney transplant activity 2002-2022”). These results were achieved under the leadership of Luigi Biancone (nephrologist and coordinator of the kidney transplant program), Paolo Gontero (urologist), and Aldo Verri (vascular surgeon). In addition, the center has recently achieved international recognition for the development of novel immunosuppressive strategies for rejection prevention and treatment, as well as innovative approaches to the recurrence of glomerulonephritis (in particular, primary focal segmental glomerulosclerosis and IgA nephropathy).
In 1986, a renal transplant program was established in Parma, primarily by Gian Carlo Botta (surgeon).
In 1988, the kidney transplantation program was reactivated in Padua, following the initial cases performed in 1974. The new phase was led by Ermanno Ancona and Paolo Rigotti. It progressively expanded and became one of the most active programs in Italy, introducing several innovations, including the development of dual kidney transplantation (which had been introduced in 1997 by the Bergamo group), an approach in which the Padua group gained international recognition by maximizing organ utilization from extended-criteria and elderly donors. Its experience includes one of the largest published series worldwide of dual kidney transplantation, with more than 350 procedures performed 5. The center has also played a major role in living donation strategies, becoming one of the highest-volume Italian programs for living-donor kidney transplantation, with activity levels comparable to international standards. In 2018, Lucrezia Furian, the current Chair of the Kidney and Pancreas Transplantation Unit in Padua, developed the DEC-K program, the first deceased donor-initiated kidney exchange chain, which was implemented nationally by the CNT in 2019 6.
In 1989, another renal transplant program was started in Bergamo by Giuseppe Locatelli (surgeon) and Giuseppe Remuzzi (nephrologist). In the 1990s, additional programs were initiated in Florence (1991, Ruggero Lenzi – urologist) and Perugia (1992, Ugo Mercati – surgeon). In the 2000s, further programs were established in Siena (2000, Mario Carmelli – surgeon from Pisa) and in L’Aquila (Antonio Famulari – surgeon from Rome Policlinico Umberto I).
Among the milestones in the history of transplantation in Italy, it is worth recalling the first systematic use of unrelated living donors at the Policlinico Umberto I in Rome, leading to the report of the first series of 100 cases in 1994 7. Unrelated living-donor renal transplantation became widely feasible largely due to the availability of newer and more effective immunosuppressive agents such as cyclosporine.
To overcome the disparity between the supply of deceased donors and demand, a key milestone in the history of kidney transplantation has been the introduction of dual kidney transplantation, i.e., the use of two marginal kidneys from donors older than 60 years or affected by diabetes or hypertension in a single recipient. This approach results in a greater number of functioning nephrons than transplantation of a single suboptimal organ and may approximate the nephron mass of a single ideal kidney 8.
This strategy was particularly needed in Italy due to the rapid ageing of deceased donors beginning in the late 1990s, which led marginal kidneys to become the standard organs offered for transplantation. To address this need, in 1997 the transplant center in Bergamo introduced the dual kidney transplantation technique in Italy, which was subsequently adopted by other centers (such as Turin in 1998, Padua in 1999, and Pisa in 2000). In addition, in collaboration with several international transplant centers (Boston, USA; Toronto, Canada; and Barcelona, Spain), the Bergamo group proposed a protocol to guide the selection and allocation of kidneys from donors older than 60 years, based on pre-transplant histological evaluation to quantify preserved tissue and predict post-transplant graft performance 9. The assumptions underlying this histological algorithm were validated in a prospective cohort study, which demonstrated that long-term survival of single or dual kidney grafts from donors older than 60 years was excellent, provided that grafts were histologically assessed prior to implantation 10. This approach also facilitated the successful use of kidneys from donors aged over 70 11 and even 80 years 12, thereby further expanding the donor organ pool for kidney transplantation.
In the 2000s, living-donor kidney transplantation expanded through the development of specialized programs. Arguably, the most transformative milestone was the first minimally invasive (laparoscopic) living-donor nephrectomy, performed in Pisa by Andrea Pietrabissa on 27 April 2000. The donor was a 58-year-old mother of a 38-year-old recipient who had been on dialysis for 11 years; the kidney was transplanted by Ugo Boggi. The graft functioned for 25 years. This landmark procedure contributed to a subsequent increase in living donation in Italy (Fig. 6). To promote the dissemination of laparoscopic donor nephrectomy in Italy, in the following years the Pisa group organized dedicated training courses, hosted surgeons from other institutions (including international guests), and directly mentored the implementation of the technique in several centers (Bologna, Catania, Padua, Parma, Rome-Ospedale Bambino Gesù, Palermo-ISMETT, Siena, and Varese).
In 2001, Ignazio Marino performed a living-donor kidney transplantation in an HIV-positive recipient.
On 15 November 2005, Ugo Boggi (surgeon) (Fig. 7), in collaboration with Gaetano Rizzo (nephrologist), performed in Pisa Italy’s first kidney paired exchange involving three incompatible donor-recipient pairs (two ABO-incompatible and one with a positive crossmatch) 13. This milestone laid the foundation for the development of national paired exchange programs, international exchange (“cross-over”) initiatives, altruistic (Samaritan) kidney donation, and DEC-K (kidney domino exchange chains initiated by deceased-donor donation – first performed in Padua in 2018).
The organization of these kidney exchange programs across multiple transplant centers benefited from logistical models already successfully established in deceased-donor transplantation. In particular, close collaboration with law enforcement agencies and the Italian Air Force has been instrumental in ensuring the rapid and secure transport of organs between transplant centers. For ground transportation, cooperation with the State Police has often been crucial; in several instances, the use of high-performance vehicles such as the Lamborghini Huracán has allowed exceptionally rapid transfer times, thereby contributing significantly to the success of these complex transplant procedures (Fig. 8).
Like several other pioneering initiatives, this early Italian experience in kidney paired exchange was not initially met with enthusiasm. On the contrary, the CNT convened an audit in Rome, which took place in an atmosphere of tension and skepticism, during which Profs. Ugo Boggi and Gaetano Rizzo were subjected more to interrogation than to objective evaluation. Despite this tense environment, Profs. Ugo Boggi and Gaetano Rizzo responded point by point to the numerous criticisms raised, including those from representatives of NIT, AIRT, and OCST. Ultimately, considering the clearly innovative nature of the procedure and the existence of an adequate legal framework, the CNT subsequently issued, on 20 November 2006, the national protocol governing this activity.
This marked the beginning of broader programmatic development and enabled further initiatives, such as the first Samaritan chain, initiated in Pavia on 7 April 2015 by Andrea Pietrabissa. This chain resulted in six transplants performed across Siena, Pisa, and Milan, and concluded with allocation of the final kidney to the deceased-donor waiting list in Lombardy.
The first international kidney exchange was performed on 19 July 2018 between Pisa and Barcelona. Shortly before, in March 2018, Lucrezia Furian (Padua) had initiated the first kidney domino exchange chain based on a deceased donor rather than an altruistic living donor (K-DEC).
The first ABO-incompatible living-donor kidney transplantation in Italy was performed in August 2008 in Parma by Enzo Capocasale, using preoperative plasmapheresis followed by standard postoperative immunosuppression. The donor was the wife (blood group A) and the recipient the husband (blood group O).
In September 2008, Massimo Abelli at Pavia Polyclinic performed the first cadaveric kidney transplant after circulatory death in a 57-year-old man who had been on dialysis for three years 14.
Minimally invasive donor nephrectomy techniques further evolved in 2008, when the first robotic living-donor nephrectomies were performed by Ugo Boggi (Pisa, pure robotic technique) and Luciano Gregorio De Carlis (Milan-Niguarda, hand-assisted approach). In June 2010, Pietrabissa, then at Pavia, performed a robotic donor nephrectomy with transvaginal graft retrieval, in collaboration with Massimo Abelli and the gynaecologist Arsenio Spinillo 15.
On March 13, 2010, Ugo Boggi (Pisa) performed the first living-donor single-incision laparoscopic donor nephrectomy (Single Incision Laparoscopic Surgery – SILS) in the context of a father-to-daughter kidney donation.
On July 3, 2010, Ugo Boggi (Pisa) performed Europe’s first robotic kidney transplant using the Da Vinci Si system and on march 13, 2010 performed the first single-access laparoscopic living donor nephrectomy, followed by Italy’s first laparoscopic kidney transplant in February 2015 16. After an initial period of development, robotic renal transplantation was also implemented in Bari, Cagliari, Florence, L’Aquila, Milan (Niguarda), Modena, Naples, and Rome (Tor Vergata).
Starting in 2010, Ugo Boggi (Pisa) performed several robotic renal autotransplantations following extracorporeal repair of renal artery aneurysms that were not amenable to endovascular radiological treatment. This experience also includes bilateral renal autotransplantations using a staged approach, i.e. treating one side at a time while postponing repair of the contralateral renal artery.
Following years of attempts to minimize conventional immunosuppressive regimens in order to prolong graft survival and reduce late complications after kidney transplantation 17, in 2011 Giuseppe Remuzzi and colleagues at Ospedali Riuniti Bergamo reported, for the first time worldwide, the early results of a pilot safety and feasibility study based on peri-transplant infusion of autologous bone marrow-derived mesenchymal stromal cells (MSC) in two recipients of kidney transplants from living related donors 18. The rationale for this cell-based approach was the induction of immune tolerance, i.e., stable graft function without the need for immunosuppressive medications, which expose recipients to an increased risk of infections, cancer, and cardiovascular disease. Successful induction of immune tolerance in a living-donor kidney transplant recipient provided evidence that modulation of the host immune system with MSCs can enable the safe withdrawal of maintenance immunosuppressive therapy while preserving optimal long-term renal allograft function 19.
On February 10, 2015, Ugo Boggi (Pisa) performed the first laparoscopic renal autotransplantation in Italy in a patient requiring extracorporeal repair of a complex renal artery aneurysm not amenable to endovascular treatment. Although the procedure would clearly benefit from robotic assistance, due to its superior dexterity in complex intracorporeal suturing, a laparoscopic approach was adopted because access to the robotic platform was limited by economic and organizational constraints. This case highlights the fact that, despite the technical advantages of robotic surgery, such systems are not yet universally available even in centers where they exist. This limitation underscores the need, in modern transplant surgery, to develop strategies that ensure broader and more systematic use of robotic platforms for organ implantation. The relevance of this issue is further reinforced by the fact that minimally invasive organ transplantation, particularly in kidney surgery, is already entering the era of clinical guideline-based practice (Fig. 9) 20.
In the history of kidney transplantation in Italy, it is finally important to acknowledge the contribution and legacy of Luisa Berardinelli (Milan-Policlinico), a woman who succeeded in establishing herself in a professional environment that was, at the time, predominantly male. In recognition of her pioneering role in Italian transplant surgery, Prof. Berardinelli was awarded by SITO during the 44th National Congress held in Naples from 3 to 5 October 2021 (Fig. 10). Prof. Berardinelli’s milestones include: deceased-donor kidney procurement (12 November 1971), deceased-donor kidney transplantation (16 December 1979), and living-donor kidney procurement and transplantation (29 June 1983).
PANCREAS TRANSPLANTATION
In the 1960s, following experimental work on kidney transplantation, an experimental pancreas transplant program in dogs was initiated at the University of Pisa. The experimental team, comprising Enrico Cavina, Gianfranco Caldarelli, Franco Mosca, and Giovanni Guajana, was led by Achille Sicari, all affiliated with the Clinica Chirurgica under the direction of Mario Selli. This pioneering work was first reported in the Bollettino Medico Chirurgico Pisano, October-December 1967, Volume XXXV, Number 4 (Fig. 11). The surgical technique employed segmental pancreatic grafting with pancreatic duct ligation, a method typical of the era. Furthers studies on experimental segmental pancreas transplantation in dogs were performed By Salvatore Agnes, at Policlinico Agostino Gemelli in Rome (1979) 21.
In 1981, Raffaello Cortesini and colleagues at Sapienza University of Rome performed the first simultaneous kidney-pancreas transplantation using a whole-organ pancreaticoduodenal graft with enteric drainage; immunosuppression consisted of azathioprine and corticosteroids. Four years later, Valerio Di Carlo (surgeon), in collaboration with Guido Pozza and Antonio Secchi (both endocrinologists), initiated a pancreas transplantation research program at San Raffaele Hospital in Milan. The pancreas transplantation program at San Raffaele Hospital in Milan, which predominantly focused on simultaneous kidney-pancreas transplantation, remained for many years the most active in Italy.
Subsequent Italian centers included Padua in 1991 (Paolo Rigotti), Milan-Niguarda in 1992 (Lino Belli), Pisa in 1996 (Franco Mosca), and Parma in 1998 (Gian Carlo Botta). Other centers included: Ancona, Bergamo, Genoa, Palermo ISMETT, Rome San Camillo, Roma Tor Vergata, Turin, and Udine.
In 2004, at Milano-Niguarda Hospital, Luciano Gregorio De Carlis and Vincenzo Sansalone performed the first combined liver and pancreas transplant in a young patient with cirrhosis and type 1 decompensated diabetes (Fig. 12).
In 2006, pancreas transplantation was extended to HIV-positive recipients. The first simultaneous pancreas–kidney transplant in this context was performed at Varese Hospital by Renzo Dionigi, in collaboration with Ugo Boggi (from Pisa), Alberto Marconi, and Patrizio Castelli. The recipient was a 32-year-old male with diabetic nephropathy, chronic uremia, and HIV infection. Pre-transplant viral load suppression was achieved using antiretroviral therapy according to a protocol designed by Paolo Grossi. Following the first combined pancreas-kidney transplantation three other patients living with HIV underwent pancreas-kidney transplantation in Varese 22.
Overall, the highest number of pancreas transplants in Italy has been performed in Pisa and at San Raffaele Hospital in Milan. In particular, the activity of the Pisa transplant center increased markedly in the early 2000s, when approximately 40 pancreas transplants were performed annually. In total, more than 500 pancreas transplants have been carried out in Pisa, including approximately 100 pancreas-alone procedures, making it by far the most active center in Italy for this indication and one of the most active worldwide. The long-term outcomes of pancreas transplant alone have been widely published in several international journals, and in particular in Transplantation, which, on the occasion of the 10-year actual results, also published an editorial by Robert Stratta and Jonathan Fridell stating: “In the previous century, Dr. David Sutherland and the group at the University of Minnesota were the original torch bearers for PTx in general and PTA in particular. In the new millennium, the torch has been passed to others, such as Dr. Ugo Boggi and the group at the University of Pisa” 23-29.
The Pisa group, and particularly Ugo Boggi (surgeon) along with Gaetano Rizzo (Nephrologist) and Piero Marchetti (endocrinologist), also introduced in Italy the simultaneous kidney transplantation from a living donor and pancreas transplantation from a deceased donor 30. In addition, the Pisa group described the technique of retroperitoneal pancreas transplantation with portal venous drainage, accumulating one of the largest worldwide experiences with this type of drainage, and performed the world’s first robotic pancreas transplantation in 2010 (initially as a solitary pancreas transplantation on September 27, 2010, and subsequently as simultaneous kidney and pancreas transplantation on October 15, 2010) (Fig. 13) 31,32. Only the Milan Niguarda center has performed another case of simultaneous robotic kidney and pancreas transplantation in Italy, in December 2025.
During this important trajectory of Italian pancreatic transplantation, Antonio Secchi (2002-2005) and Lorenzo Piemonti (2025-2027), both from San Raffaele Hospital in Milan, served as Presidents of the International Pancreas and Islet Transplant Association (IPITA). Within the IPITA framework, Antonio Secchi also delivered the Paul Lacy Award Lecture in 2019. Furthermore, Italy has hosted the IPITA World Congress on three occasions: in 1997 in Milan, in 2009 in Venice, and in 2025 in Pisa. The 2025 IPITA World Congress in Pisa was dedicated to the memory of Prof. David Sutherland, a pioneer of pancreatic transplantation, who passed away on 23 March 2025 (Fig. 14).
It is also important to note that the final assembly phase leading to the development of the only international guidelines for pancreas transplantation was held in Pisa from 17 to 19 October 2019. This landmark initiative, which represents a major milestone in the history of pancreas transplantation and remains unique to date, was chaired by Ugo Boggi (Pisa), with the support of an organizing committee composed of Piero Marchetti (Pisa), Raja Kandaswamy (Minneapolis, USA), Thierry Berney (Geneva, Switzerland), and Fabio Vistoli (Pisa). The guidelines were subsequently published in the American Journal of Transplantation (Fig. 15) 33,34.
Finally, from the European side, Ugo Boggi from Pisa was among the founding members of the European Pancreas and Islet Transplant Association (EPITA), established in Prague (Czech Republic) on the 13th Congress of the European Society for Organ Transplantation (ESOT).
ISLET CELL TRANSPLANTATION
Although pancreatic islet transplantation is a form of cell transplantation, its aim is to restore deficient beta-cell mass and thereby achieve endocrine outcomes like those of pancreas transplantation. While islet transplantation does not represent a true alternative to pancreas transplantation, since the achievement of insulin independence is more consistent in organ transplantation and less frequent and less durable in islet transplantation, it remains the only form of cell transplantation capable of replacing the deficient function of an organ, specifically the endocrine component of the pancreas. For this reason, we believe it is appropriately addressed within this context.
Italian contributions to pancreatic islet transplantation have been numerous. Not infrequently, these have resulted from the work of Italian researchers who spent periods conducting research abroad or who relocated internationally, particularly to the United States of America.
Perhaps the clearest example of this paradigm is provided by Camillo Ricordi. A breakthrough was the development of the Ricordi Chamber, an automated method for human islet isolation that significantly improved the yield, reproducibility, and viability of isolated pancreatic islets. This technology was first described in 1988 and remains in widespread use today 35. In addition, Ricordi played a major organizational role in the XIX International Congress of the Transplantation Society (TTS), held in Miami in 2002. He served as President of the Cell Transplant Society (2002-2004) and played a central role in the establishment and development of the Diabetes Research Institute in Miami. Ricordi has directed the Diabetes Research Institute since its foundation.
Another example of Italians who have distinguished themselves abroad is provided by the work of the then-young Italian researcher Piero Marchetti from Pisa. While working at Washington University in St. Louis as part of Paul Lacy’s team, Marchetti successfully isolated viable pancreatic islets from a human pancreas, leading, for the first time, to insulin independence following transplantation. This landmark achievement represents the first fully successful case of islet cell transplantation worldwide 36.
The first case of islet cell transplantation in Italy was performed on January 6, 1989, in Cagliari, in conjunction with a kidney transplant. The pancreatic islets were isolated in Perugia by Riccardo Calafiore at the Laboratory for the Study and Transplantation of Pancreatic Islets within the Institute of Internal Medicine and Endocrine and Metabolic Sciences (IMISEM). This laboratory became specialized in the development of alginate-based microencapsulation of isolated islets. Microcapsules were designed to create physical barriers around individual islets to prevent graft-directed immune responses, by blocking direct contact between islets and the host immune system, thereby reducing or eliminating the need for recipient immunosuppression. For the first Italian case, islets were obtained from a 12-year-old deceased donor and subsequently transported to Cagliari for transplantation. The recipient was a 40-year-old patient with type 1 diabetes mellitus. The first Italian islet transplant was in fact a kidney-islet combined transplantation, since the patient also suffered from end-stage renal failure. Consequently, immunosuppression was already required for the kidney graft (after induction with steroids and anti-lymphocyte globulin, maintenance immunosuppression consisted of steroids, cyclosporine, and azathioprine). The post-transplant metabolic response, however, was transient, with a limited reduction in exogenous insulin requirements and no detectable C-peptide response following glucagon stimulation.
Building on the concept that microcapsules could protect pancreatic islets from the alloimmune response, Riccardo Calafiore performed in 1989 the first transplantation of microencapsulated pancreatic islets in a non-immunosuppressed recipient. The microencapsulated human islets were placed inside a dedicated vascular prosthesis consisting of two coaxial chambers (an inner Dacron layer with 150 μm pores and an outer impermeable PTFE layer), manufactured at the University Hospital of Cagliari by Giovanni Brotzu (vascular surgeon). The rationale was to lodge islet-containing microcapsules between the two layers of the prosthesis so that they would be perfused by plasma ultrafiltrate after the establishment of an arterial bypass, representing an early example of an intravascular chamber for islet transplantation, previously tested only in animal models. The recipient was a man in his 60s with type 2 diabetes, strictly insulin-dependent for the previous five years (approximately 90 U/day of combined short- and long-acting insulin), with poor metabolic control. His clinical history included right lower-limb amputation due to diabetic macroangiopathy and severe obstruction of the ipsilateral iliac artery requiring surgical revascularization. For this procedure, a long axillary-femoral arterial bypass was selected. The operation was completed without surgical complications. In the early postoperative period, the patient showed progressive reduction of blood glucose levels and decreased exogenous insulin requirements. Functional graft activity was confirmed by plasma C-peptide levels at 18 days post-transplant (0.8 nmol/L at baseline and 2.0 nmol/L after glucagon stimulation). Insulin therapy was temporarily discontinued for one week, although it was later reintroduced at a dose approximately five times lower than baseline. At eight months, C-peptide levels were 0.4 nmol/L at baseline and 0.8 nmol/L after stimulation. In early 1990, a second patient received a vascular graft containing microencapsulated human islets at the Policlinico Umberto I in Rome, with islets prepared and encapsulated in Perugia. The 40-year-old patient had type 1 diabetes and had previously undergone pancreas transplantation with only transient metabolic benefit. The device was implanted as an axillary vein–brachial artery arteriovenous shunt. Pre-transplant plasma C-peptide was undetectable. After transplantation, blood glucose levels rapidly decreased, and C-peptide became detectable, reaching 0.5 nmol/L at 12 days and remaining stable for approximately 45 days. In parallel, exogenous insulin requirements were reduced by about 50% until measurable endogenous C-peptide levels were established 37.
Another milestone achieved by the Perugia group led by Riccardo Calafiore was the world’s first intraperitoneal transplantation of microencapsulated pancreatic islets in non-immunosuppressed recipients. In 2003, this procedure was performed in four patients with long-standing type 1 diabetes mellitus (≥ 25 years). Although none of the patients had significant secondary complications of the disease, all exhibited poor metabolic control and elevated glycated hemoglobin levels. Under local anesthesia and ultrasound guidance, microencapsulated human islets were administered by simple gravity infusion into the peritoneal cavity. Graft function was demonstrated clinically by detectable C-peptide levels, significant improvement in biochemical parameters, and a 50-75% reduction in daily exogenous insulin requirements; one patient was transiently insulin-independent. These metabolic benefits persisted for up to 400 days post-transplant, after which graft function was progressively lost. Additional evidence of graft efficacy was provided by the disappearance of nocturnal hypoglycemia unawareness in all recipients. Importantly, no immune sensitization against islet cell antigens was observed. At three years post-transplantation, all patients tested negative for islet cell antibodies (ICA), anti-GAD65, and anti-HLA class I and II antibodies, supporting the immunological barrier function conferred by the microcapsule technology 38-40.
The development of clinical islet transplantation in Italy was largely centered at San Raffaele Hospital in Milan, where the first islet transplantation was performed in 1989, shortly after the case performed in Cagliari. The program was initially led by Guido Pozza and subsequently by Antonio Secchi, both endocrinologists. Secchi and his multidisciplinary team, including Lorenzo Piemonti, Federico Bertuzzi, and Paola Maffi, played a key role in translating islet transplantation from experimental research into clinical practice in Italy. The group also collaborated with Camillo Ricordi, who was originally affiliated with San Raffaele Hospital, having begun his surgical training at the School of Valerio Di Carlo. The islet transplantation program at San Raffaele Hospital was by far the most active in Italy and made substantial contributions to the international advancement of the field 41,42.
Subsequently, additional clinical programs were established in Pisa, Milan (Niguarda Hospital), Padua, and Palermo (ISMETT). In addition to islet allotransplantation (performed either as isolated islet transplantation or simultaneously with kidney transplantation in patients too fragile for combined kidney-pancreas transplantation, or following kidney transplantation) Italy also developed islet autotransplantation programs, primarily at San Raffaele Hospital in Milan and in Pisa. Autologous islet transplantation was applied in patients requiring total pancreatectomy due to complications of pancreatic resections, or in cases of pancreatic head tumors in which complete pancreatectomy was deemed necessary, including removal of the non-neoplastic pancreatic body and tail. Less frequently, in Italy, islet autotransplantation was also used in non-diabetic patients with severe chronic pancreatitis not manageable by any means other than total pancreatectomy 43.
LIVER TRANSPLANTATION
Due to is intrinsic complexity, clinical success in liver transplantation was achieved later than in kidney transplantation. Thomas Starzl (1926-2017), after extensive experimental research in animals at the University of Colorado School of Medicine in Denver and a series of unsuccessful human liver transplantations in 1963, achieved clinical success in 1967 with transplants performed in children affected by various liver diseases. Thanks to Starzl’s work, the Department of Surgery at the University of Pittsburgh, previously not particularly prominent, became one of the most important surgical centers in the United States. Outcomes of liver transplantation improved markedly toward the end of the 1970s with the introduction of cyclosporine in postoperative therapy and further improved with the adoption of tacrolimus as standard immunosuppression. In its mature phase, the liver transplantation program established by Thomas Starzl in Pittsburgh became the most active in the world. Hundreds, if not thousands, of surgeons from all over the world trained in liver transplantation in Pittsburgh, including many Italian surgeons. Following the passing of Thomas Starzl, SITO decided to dedicate an annual award in his memory, presented for the best scientific contribution during the Society’s National Congress.
The history of liver transplantation in Italy has been particularly significant and characterized by numerous milestones that represent world firsts, including the first experimental liver transplantation performed by Vittorio Staudacher in 1952 44; the introduction of the concept of transplant oncology in a seminal paper by Vincenzo Mazzaferro, who has since remained a world leader in this field 45; the description in 1999 by Michele Colledan of the first case of deceased-donor liver splitting for transplantation into two adult recipients 46; the first fully robotic right hepatectomy for living donation and adult-to-adult transplantation, performed by Ugo Boggi from Pisa at ISMETT in Palermo 47; and the first world series of cold ischemia free preservation in cDCD donors by Umberto Cillo.
Liver transplant activity in Italy began in the 1980s, following a long experimental phase in dogs and pigs, when Raffaello Cortesini performed the first liver transplant in Rome in 1982 at Policlinico Umberto I (Fig. 16). The liver was donated by a young English boy who died following a road traffic accident and was transported to Rome, to Ciampino Airport, aboard a DC-9 aircraft of the Italian Air Force, where it was received by Dario Alfani. The procedure involved Pasquale Berloco, Dario Alfani, and Antonio Famulari 48.
In 1983, after two decades of experimental liver transplantation in dogs, Dinangelo Galmarini and Luigi Rainero Fassati established a liver transplantation program at the Milan Polyclinic (Fig. 17) 49,50.
In 1984, Giuseppe Gozzetti performed the first liver transplant in Bologna (Fig. 18).
In 1986, Lino Belli initiated a liver transplant program at Niguarda Hospital in Milan (Fig. 19). This program expanded in subsequent years, supported by an organ donation network including living donors and donors after circulatory death (DCD).
In 1986, Umberto Valente and colleagues performed the first liver transplant in Genoa (Fig. 20). Notably, in 2004, they transplanted a liver from a 97-year-old cadaveric donor into a 64-year-old female recipient, a record since surpassed by other Italian centers.
In 1987, Marco Castagneto performed the first liver transplant at the Policlinico Agostino Gemelli in Rome. The program, characterized by a high prevalence of patients with decompensated cirrhosis (which today would correspond to a MELD-Na ≥ 28), was led by Salvatore Agnes from 2013 and is currently directed by Sergio Alfieri.
In 1990, Mauro Salizzoni, in collaboration with hepatologist Antonio Ottobrelli and transplant coordinator Emilio Sergio Curtoni, performed the first liver transplant at Molinette Hospital in Turin. The program subsequently expanded rapidly, ultimately becoming the Italian center with the highest annual volume of liver transplantation. On November 25, 2023, under the direction of Renato Romagnoli, the center performed its 4,000th liver transplant (Fig. 21). Salizzoni made several key contributions to the development of liver transplantation in Italy. Perhaps the most relevant was the expansion of the donor pool through the successful use of livers that had previously been considered unsuitable for transplantation and therefore discarded.
In 1990, Davide Francesco D’Amico, in collaboration with Nicolò Bassi, Umberto Tedeschi, and Umberto Cillo, performed the first liver transplant in Padua.
In 1991 the Istituto Nazionale dei Tumori in Milano began its activity under the direction of Leandro Gennari and, in 1996, Vincenzo Mazzaferro (currently head of the program) published the seminal paper showing for the first time that liver transplantation represented an optimal and highly effective treatment for a strictly selected subpopulation of patients with hepatocellular carcinoma in cirrhosis 45. This paper opened access to liver transplantation to a condition that was previously considered a contraindication. The “Milan criteria” were rapidly and universally adopted and continue to represent an international reference standard; in fact, they marked the beginning of the era of so-called transplant oncology, to which Vincenzo Mazzaferro has made numerous fundamental and widely recognized contributions worldwide 51,52.
In 1996, a liver transplantation program was established in Pisa under the leadership of Franco Mosca. The team performing the first four transplants (in three patients) included Franco Mosca, Franco Filipponi, and Pier Cristoforo Giulianotti, who later became one of the world’s leading robotic surgeons and is credited with performing several procedures for the first time worldwide, including the first robotic pancreatoduodenectomy, the first robotic kidney transplantation, and the first hand-assisted robotic living donor right hepatectomy for adult-to-adult liver transplantation 53-55. Following these initial cases, the program continued with Franco Mosca, Franco Filipponi, and Ugo Boggi; Mario Carmellini also participated in selected procedures. With the adoption of the so-called Spanish model of organ donation in Tuscany starting in 1999, and the consequent substantial increase in deceased donors, the liver transplant program in Pisa, largely driven by the contributions of Franco Filipponi and Ugo Boggi, became one of the most active in Italy, with an annual volume eventually exceeding 150 procedures. After the retirement of Franco Filipponi in 2017, the program was led by Paolo De Simone and is currently directed by Davide Ghinolfi.
In October 1997, Davide D’Amico and Koichi Tanaka performed Italy’s first living-donor liver transplantation in a pediatric patient. This landmark procedure was broadcast live during the 99th Congress of the Italian Society of Surgery, held from 19 to 22 October 1997 in Padua (Fig. 22).
In March 2001, Domenico Forti and Luciano Gregorio De Carlis performed the first living donor liver transplant in adult patients at Milano-Niguarda, followed a few months later by Antonio Daniele Pinna and Elio Jovine in Modena.
The first liver transplant from a DCD (donation after circulatory death) donor in Italy was performed in Pisa in 2005 by Franco Filipponi; the recipient did not survive, and the procedure was not publicized. The first successful DCD liver transplant in Italy was performed in 2015 at Milan Niguarda, marking a significant milestone in liver transplantation.
In 1988 in Milan, Bruno Gridelli had started the first program of pediatric liver transplantation progressively introducing in the 90’s the techniques of reduced-sized and split-liver transplantation. In 1997, after moving to Bergamo, Gridelli, in a collaborative effort involving four additional centers (Genoa, Milan Policlinico, Milan Niguarda, and Padua), designed and implemented a strategy based on the extensive use of the split-liver technique. This approach led, for the first time worldwide, to a dramatic reduction in waiting list size and waiting times, with a subsequent virtual elimination of waiting list mortality 56,57. As a secondary effect, this policy allowed the progressive diffusion of the split liver technique to most Italian centers, with widespread sharing of the grafts, becoming a reference model for most western counties 58,59. In 1999, Michele Colledan reported the first successful case of transplantation of two adult-sized patients from the same donor, by a modified, more complex split liver technique 46.
In September 2002, Eugenio Santoro and his collaborators (Giuseppe Maria Ettorre and Giovanni Vennarecci) performed the first liver transplantation in an HIV-positive patient at the Istituto Tumori Regina Elena in Rome, marking a turning point in transplant eligibility criteria. This pioneering experience was subsequently recognized in 2004 with the Gold Medal for Merit in Public Health awarded to Santoro by the President of the Italian Republic, Carlo Azeglio Ciampi (Fig. 23) 60,84.
In 2004, D’Amico and Tanaka successfully used the split-liver technique to transplant a liver segment from a living donor who was the recipient’s twin.
In 2007, Umberto Cillo performed Italy’s first auxiliary liver transplantation in a 7-year-old child with fulminant hepatic failure due to isoniazid poisoning; the patient is still alive and in good health today.
The first liver autotransplant in Italy was performed by Renzo Dionigi in Varese in the 1990’s The procedure was carried out in a patient with a giant hepatic hemangioma weighing approximately 6 kg. The patient is still alive today.
In 2008, Giuseppe Maria Ettorre, currently at San Camillo Hospital in Rome, described the use of a 180-degree rightward rotation technique for transplantation of the left hepatic lobe following split liver procurement from a deceased donor for transplantation into two adult recipients. Previously, this technique had been applied only to partial liver grafts from living donors or to left lateral segments, and not to the entire left hemiliver 61.
In 2010, Ugo Boggi performed Italy’s first laparoscopic live donor left lateral segmentectomy in Palermo (ISMETT) for adult-to-child liver transplantation and subsequently trained the local surgical team, led by Marco Spada, to independence 62. On April 17, 2012, Ugo Boggi performed the world’s first fully robotic right hepatectomy for adult-to-adult liver transplantation 47. This milestone was closely preceded by Piero Giulianotti in Chicago, USA, who performed a similar procedure using a hand-assisted robotic technique 55.
A full robotic right hepatectomy from a living donor was subsequently performed in Modena in 2022 by Fabrizio Di Benedetto and was later applied in 18 living donor hepatectomies. Three years later, in February 2024, Di Benedetto, in collaboration with Stefano Di Sandro and Paolo Magistri, performed Italy’s first fully robotic liver transplantation using a full-size graft in a 66-year-old male recipient 63. This procedure was among the first three fully robot-assisted liver transplants reported worldwide. To date, the Modena center has performed 43 full-size robotic liver transplants, representing a world record series.
Several additional pioneering applications of robotic assistance were also first introduced in Modena. These include the first implantation of a partial liver graft in an adult recipient following a split procedure, in which the left lateral segment was allocated to a pediatric recipient (February 2025); the first robotic liver-kidney transplantation using a delayed technique (May 2025); and the first European living-donor robotic hepatectomy followed by robotic implantation of the donated hemiliver (June 2025). Finally, in 2025, Umberto Cillo performed in Padua the first two cases of Machine Perfusion (MP) supported robotic liver transplantation from a deceased donor with the aim to maintain the graft perfused throughout the whole robotic implantation phase.
In 2015 a collaborative national effort including all the Italian liver transplant centers created an innovative, blended-principle based allocation system and the “ISO score” for organ allocation representing a rational and measurable system to distribute scarce resource, even today recognized internationally 64.
In July 2019, G.M. Ettorre performed in Rome one of the first liver transplants in a patient with unresectable breast cancer liver metastases. This procedure was carried out within a specific national protocol, representing an example of the expanding concept of transplant oncology and the progressive extension of transplant indications to tumor types traditionally considered a contraindication for liver transplantation 65.
In November 2020, contemporaneously, thanks to a special experimental protocol of the Italian Center for Transplantation, Salvatore Gruttadauria in Palermo and Renato Romagnoli in Turin performed respectively the world first ever adult and pediatric liver transplant with liver grafts coming from donors infected by SARS CoV-2 virus 66.
As already mentioned, one of the most rapidly evolving fields in liver transplantation is the so-called transplant oncology, a concept originally conceptualized by Vincenzo Mazzaferro. This approach is grounded in solid principles of medical oncology and therefore continues to evolve in parallel with advances in medical oncology and molecular biology. A key conceptual framework of transplant oncology is the notion of a therapeutic hierarchy, developed in Padua, in which treatment options are ranked according to expected survival benefit 67.
Because the extension of oncological indications raises ethical and practical concerns regarding the allocation of deceased-donor livers to cancer patients who may benefit from transplantation, transplant oncology has renewed interest in living-donor liver transplantation. However, since in adult recipients a right lobe graft is most often required, and right hepatectomy carries a non-negligible donor risk, including an estimated mortality of approximately 0.2%, new strategies are emerging in which Italian surgeons have made substantial contributions. Among these, the so-called “shift to the left” strategy is particularly relevant. It includes three main approaches: the use of the left lobe instead of the right, the use of partial grafts from two donors, and the RAPID technique (Resection And Partial Liver segment II-III transplantation with Delayed total hepatectomy), an evolution of the APOLT (auxiliary partial orthotopic liver transplantation) concept 68,69.
In Italy, both dual-graft living donor liver transplantation and the RAPID technique were introduced by Umberto Cillo in Padua. The first dual-graft living donor liver transplantation was performed in 2023 in a young woman with unresectable colorectal liver metastases, who was ineligible for deceased-donor listing. Two left grafts (the left lateral segment and the left lobe) were donated by her nephews. Although technically successful, the patient developed early tumor recurrence.
Cillo also pioneered the RAPID technique in Italy. Originally proposed by Line and colleagues in 2015, RAPID is conceptually similar to ALPPS (associating liver partition and portal vein ligation for staged hepatectomy). In patients with high tumor burden, segments I-III are resected and an auxiliary orthotopic liver graft (segments II-III) is implanted. Portal inflow to the native liver is ligated to promote graft hypertrophy, while portal pressure is carefully modulated (< 15 mmHg in cirrhotic and ≤20 mmHg in non-cirrhotic patients). Once sufficient regeneration of the future liver remnant is achieved, completion hepatectomy of the native liver is performed as a two-stage strategy. Umberto Cillo performed also the first laparoscopic RAPID second stage to reduce the procedure invasiveness 70. A prospective study evaluating RAPID in patients with unresectable colorectal liver metastases (BRAF wild-type) is currently ongoing in Padua (ClinicalTrials.gov identifier: NCT04865471). More recently, Giuseppe Maria Ettorre and collaborators applied the RAPID protocol using a whole pediatric liver graft, representing a further step in the development of innovative strategies within transplant oncology.
Finally, although not strictly related to liver transplantation, it is worth mentioning a significant contribution by Bruno Nardo (currently based in Cosenza), who in March 2001, while working in Bologna under the direction of Prof. Antonino Cavallari, described portal vein arterialization as a rescue strategy in patients developing early hepatic artery thrombosis after liver transplantation when early revascularization or retransplantation is not feasible. In a representative case, a 40-year-old man developed complete hepatic artery thrombosis seven days after liver transplantation, with 80% hepatic necrosis documented on biopsy. The hepatic artery was anastomosed end-to-side to the portal vein in order to enhance hepatic oxygen delivery and promote regeneration. Following the procedure, the patient’s clinical condition rapidly improved, and serial biopsies demonstrated progressive regression of necrosis (30% at 10 days and 10% at 24 days), with minimal cholestasis. However, an ischemic biliary stricture developed after two months, and the patient subsequently underwent retransplantation in July 2001 71. Nardo later extended the application of this technique to extended hepatectomy cases at risk of small-for-size syndrome, including the use of an extracorporeal device to modulate portal inflow 72.
INTESTINAL AND MULTIVISCERAL ORGAN TRANSPLANTATION
Intestinal transplantation is a heterogeneous entity that includes transplantation of the small bowel, with or without the liver, stomach, pancreas, and a portion of the large intestine, depending on the specific clinical needs of the patient. Three major types of transplantation are currently recognized: isolated small bowel transplantation, liver-intestine transplantation (usually including the duodenum and pancreas), and multivisceral transplantation (also including the stomach) 73. A further entity, now considered obsolete, is represented by cluster transplantation of all supramesocolic organs, performed as replacement therapy after exenteration for locally advanced neoplasms 74.
In Italy, a pioneering experimental program of small bowel transplantation in dogs was performed in 1968 by Giancarlo Castiglioni at the Policlinico Agostino Gemelli in Rome 75.
In 1989, the first cluster transplant in Italy was performed at Sapienza, University of Rome, by Raffaello Cortesini and his team 76. In 2000, Antonio Daniele Pinna, together with Elio Jovine, reintroduced intestinal and multivisceral transplantation in Modena 77. Following Pinna’s subsequent move to Bologna, this activity was transferred to that center.
In April 1999, Bruno Gridelli performed the first combined liver-bowel transplant in a 10-month-old child at Bergamo Hospital. The graft was obtained from a cadaveric adult donor; the liver was split into two sections and used for two recipients. Michele Colledan performed in 2006 the first successful isolated small bowel and the first successful multivisceral transplantations in pediatric patients at Bergamo Hospital as well as, in 2019, the first living donor pediatric liver-small bowel transplantation (Figs. 24-25) 78,79.
HEART TRANSPLANTATION
The cardiac transplant program started in Italy almost 20 years after the first successful orthotopic heart transplant (HT) performed by Christiaan Barnard on December 3, 1967, at Groote Schuur Hospital in Cape Town, South Africa. Following this milestone operation many HT programs were started throughout the world. However, since the initial results were unsatisfactory due a high mortality mainly due to a significant incidence of acute rejection episodes, many such programs were reduced or even abandoned. Worldwide interest in HT restarted after the clinical introduction in the early 1980’s of cyclosporine as a more effective immunosuppressive agent.
In Italy, Prof. Luigi Donato (CNR-Pisa) was responsible for the planning, organization, and launch of the National Heart Transplant Program, serving for many years as chair of the Ministry of Health Committee for Cardiology and Cardiac Surgery (Fig. 26). The true strength of the Committee lay in its systematic monitoring of cardiac surgery activity (including case volume, types of procedures, and outcomes) in Italy since the 1970s. This approach ensured that the essential quality standards of cardiac surgery, including expertise acquired in leading international transplant centers, were integrated within a coordinated network of cardiological, immunological, immunometric, infectious disease, pathological, and other complementary disciplines, all operating at a consistently high level and in close functional integration. This multidisciplinary framework ultimately led to the identification of the first group of centers proposed for authorization to perform heart transplantation. Luigi Donato was also responsible for the selection of the type of ventricular assist device and for designating the Pavia Center for its first use as a bridge-to-transplant strategy in 1987 80.
The first heart transplantation in Italy, although performed as a heart-lung transplant (and therefore also representing the first lung transplantation in the country), was carried out by Vittorio Staudacher in Milan in 1983 (Fig. 27). This procedure is often “forgotten” in the Italian transplant history because it had an unfavorable short-term outcome and remained an isolated case.
In practice, the first successful heart transplantation in Italy, and the procedure that effectively initiated this field in the country, is universally attributed to Prof. Vincenzo Gallucci (Fig. 28).
During the night between November 13 and 14 1985, at the Division of Cardiac Surgery of Padua Hospital, Prof. Vincenzo Gallucci performed the first successful HT in Italy, a historical achievement which provided a new and important outlook for the national cardiac surgery community 81. The first recipient was a 39-year-old carpenter with a dilated cardiomyopathy who was admitted in the local intensive care unit with borderline cardiac function and kept under massive catecholamine support. The first cardiac donor in Italy was an 18-year-old male who was declared dead upon arrival at the Hospital of the nearby city of Treviso, after a car accident. Once availability and compatibility of this donor heart were confirmed, the explant team, led by Vincenzo Gallucci together with Giuseppe Faggian and Giovanni Stellin, left Padua and reached Treviso to retrieve the donor graft. In the meantime, in Padua, the recipient was brought to the operating room where the anesthesiological team, led by Carlo Sorbara, started to prepare the patient. Another surgical team, which included Alessandro Mazzucco and Uberto Bortolotti, was ready to prepare the recipient for cardiectomy. When the donor heart arrived in Padua, the recipient was put on cardiopulmonary bypass, his extremely dilated heart excised and the new graft implanted by Vincenzo Gallucci. Surgery was uncomplicated, and spontaneous regaining of sinus rhythm by the new heart witnessed that a historical moment had taken place. This patient got married 20 months later and survived almost 7 years after HT, enjoying a normal life. Unfortunately, he died in 1992, at 46 years of age, of HIV infection transmitted by a blood transfusion received when the test for HIV was not yet available 82.
The first HT in Padua was followed by the same operation performed in other Italian Institutions. Few days later, on November 18 1985, another successful HT took place in Pavia where Prof. Mario Viganò and his team (Gaetano Minzioni, Luigi Martinelli and Angelo Graffigna) implanted a new heart in a 20-year-old man who later became a lawyer and, being currently still alive, represents the longest Italian survivor after HT (Fig. 29). Subsequently, between November 21 and 23 1985 other HTs were performed in Udine (Cesare Puricelli), Bergamo (Lucio Parenzan) and Milan (Alessandro Pellegrini).
On January 6, 1986, Prof. Benedetto Marino and Prof. Michele Toscano performed the first Italian pediatric HT in a 7-year-old girl in Rome, at Policlinico Umberto I. In 1986, other centers joined the HT program including S. Camillo Hospital in Rome (Luigi D’Alessandro) and Bambin Gesù pediatric Hospital (Carlo Marcelletti) also in Rome, where, soon after the HT program was started, a one-year-old, 10 kg of weight, recipient received a new heart.
Three months after the first Italian HT, on February 16, 1986, Vincenzo Gallucci, together with the general surgeon Tommaso Tommaseo Ponzetta, head of kidney transplant program at Treviso Hospital, successfully performed also the first combined heart and kidney transplant in Europe 83. The recipient was a 41-year-old male with ischemic cardiomyopathy and chronic renal failure who received heart and kidney of a 20-year-old lady who died because of a cerebral hemorrhage. Concerning multi-organ transplantation, a meritorious series of combined heart and liver transplants was successfully carried out in Bologna (Giorgio Arpesella) mainly to treat complicated amyloidosis, when the current treatment for such disease was not yet available.
In 1988, a HT program was started in Naples (Maurizio Cotrufo) followed by Turin (Mario Morea), Bologna (Angelo Pierangeli), Catania (Mauro Abbate), Bari (Luigi De Luca Tupputi Schinosa), Verona (Alessandro Mazzucco), Siena (Michele Toscano), Chieti (Gabriele Di Giammarco), Cagliari (Valentino Martelli) and Palermo (Michele Pilato).
After the first Italian HT, also a pediatric HT program was started in Padua allowing to perform, among the first in Europe, several successful transplants in young infants and neonates with end-stage congenital and acquired heart diseases 84,85. The first HT in a neonate with a huge, not resectable left ventricular fibroma was also performed in Padua in 1987 by Vincenzo Galluci and its team (Giovanni Stellin, Giuseppe Faggian and Ugolino Livi).
Beyond the 1990s, the Italian HT programs rapidly grew further under the leadership of distinguished cardiac surgeons who contributed to the progress of cardiac transplantation in Italy with the fundamental support of many important subjects, in particular cardiologists, anesthesiologists, immunologists, infectivologists and pathologists.
Other major achievements in cardio-thoracic transplantation in Italy worth to be underlined were the following. The first domino HT (1987) and the first successful en-bloc heart and lung transplantation (1991) were performed in Pavia by a team led by Mario Viganò and including Gaetano Minzioni, Luigi Martinelli and Mauro Rinaldi. Furthermore, the second heart and lung transplantation performed by Prof. Ugolino Livi together with the thoracic surgeon Prof. Federico Rea in Padua (1998) survived a record of 18 years in good condition before his sudden, unexpected death.
The first case of donor cardiac ex-vivo preservation was performed in 2007 in Udine by the team led by Ugolino Livi (Vincenzo Tursi, Igor Vendramin and Sandro Sponga), followed by one of the largest European series of HTs using such an innovative technique 86.
In November 2006, Prof. Gino Gerosa with its team (Antonio Gambino, Giuseppe Feltrin, Giuseppe Toscano) and the contribution of immunologist (Emanuele Cozzi), pathologist (A. Angelini, G. Thiene), hematologist (Giustina De Silvestro) performed in Padua the first Italian incompatible HT using a graft from a blood type A donor in a 3-month-old newborn with blood type 0 87. More recently, on May 11, 2023, Gino Gerosa with its team (Vincenzo Tarzia, Roberto Bianco, Giuseppe Feltrin, Nicola Pradegan) and the anesthesiologist Paolo Zanatta performed in Padua the first HT in a patient with a complex operated congenital heart disease using a graft from a distant, 52-year-old donor after circulatory death (DCD) and following an exceptionally long (47 minutes) functional warm ischemic time. This first case was soon followed by further in Turin (Mauro Rinaldi), Verona (Giovanni Battista Luciani), Bologna (Davide Pacini) and other centers 88; this technique allowed cardiac donor recruitment to increase by 20% in 2025.
On May 20, 2024 Prof. Igor Vendramin with Andrea Lechiancole and Sandro Nalon, in Udine, performed the first European HT with a beating donor heart 89, followed by the world first HT from a DCD donor with a heart beating from harvesting to implant by Gino Gerosa with Vincenzo Tarzia in Padua 90.
Besides HT, also a program of mechanical circulatory assistance was started in Italy. The first implant of a left ventricular support by a pneumatic device was carried out in Padua in 1987. Few months later, in December 1987, Mario Viganò in Pavia implanted a biventricular para-corporeal support in a patient who was successfully bridged to HT. The device had been developed within the ICARUS project led by Luigi Donato (cardiologist; CNR-Pisa). In the 1990s implant of various intra-corporeal electromechanical devices was started mainly in Pavia, Milan, Padua, Rome, Naples, Udine and Verona, where the world longest (5 years) supported patient with a Novacor device was successfully transplanted by Prof Giuseppe Faggian.
Thereafter, many implants of a new VAD generation (axial and centrifugal pumps) were performed in numerous centers either as bridge to HT or as destination treatment. In 2007 the first pneumatic total artificial heart was implanted in Padua by Gino Gerosa with Maurizio Rubino in a patient who underwent successful HT 4 years later 91; a total of 55 implants of artificial hearts were performed mainly in Padua, Naples, Rome and Udine. More recently, a new model of total artificial heart, a biocompatible electrohydraulic pump, has been implanted in Naples (Ciro Maiello), Rome (Francesco Musumeci), Verona (Giovanni Battista Luciani), Milan (Claudio Francesco Russo) and Udine (Igor Vendramin), all patients have been successfully transplanted few months later. The first implant of an intra-corporeal mechanical device was implanted in a pediatric patient by Antonio Amodeo at Bambin Gesù Hospital in Rome in October 2010; thereafter, in February 2018, the first world mini-VAD was implanted in a 3-year-old, 13 kg of weight child who was transplanted one year later by the same surgeon 92.
After more than 40 years from the first historical operation, HT in Italy has evolved from an experimental stage to a well-established reality with significantly improved early and late results. The number of HTs has progressively increased from few units in the early years to a record of 461 procedures performed in 2025. Continuous technological innovations and new possibilities of donor organ recruitment, such as from DCD, will hopefully allow to face successfully the increasing demand for HT.
LUNG TRANSPLANTATION
Lung transplantation represents a relatively recent therapy in the history of medicine; however, over the past decades it has undergone remarkable development, both internationally and within the Italian context. The first experimental attempts date back to the 1960s, when in 1963 the American surgeon James Hardy performed the first lung transplant. The outcome was nevertheless limited, as the patient survived only for a short period due to the lack of effective immunosuppressive therapies able of preventing rejection. A decisive turning point occurred in the 1980s with the introduction of cyclosporine, a powerful immunosuppressive agent that enabled a significant improvement in patient survival. In 1983, thanks to the work of Joel D. Cooper in Toronto, the first truly successful lung transplant was performed, marking the beginning of the modern era of this procedure.
In Italy, a pioneering experimental program was performed in the dog by Francesco Crucitti at Policlinico Agostino Gemelli in Rome in 1969 93. Francesco Crucitti was internationally renowned for having saved Pope John Paul II following the assassination attempt on May 13, 1981 (Fig. 30).
Clinical transplantation programs in Italy began in the late 1980s and were fully established in the early 1990s. The first procedure was performed in January 1991 in Rome by Costante Ricci, in collaboration with Federico Venuta and Erino Rendina.
Shortly thereafter, in March of the same year, the Policlinico of Milan followed under the leadership of Giuseppe Pezzuoli. During this initial phase, the procedure was considered extremely complex and highrisk, both because of surgical technical challenges and the limited knowledge regarding postoperative management. Following these early successes, seven additional lung transplant centers were progressively established in Italy (Pavia 1992, Policlinico Agostino Gemelli in Rome 1993, Turin 1994, Padua 1995, Siena 2001, Bergamo and Bologna 2002, Palermo 2005).
Over time, the experience of Italian centers expanded significantly with the development of highly specialized programs. This enabled a broader spectrum of indications, the implementation of combined multiorgan transplantation, and the establishment of dedicated pediatric programs. The first successful combined lung and liver transplantation in Italy was performed in Bergamo in 2002 by Bruno Gridelli and Michele Colledan. In this context, in July 2004, the first pediatric bilateral lung transplant was performed in Bergamo under the direction of Michele Colledan in a child with cystic fibrosis. The same group, in subsequent years, also introduced the use of segmental and split lung transplantation, still in patients with cystic fibrosis.
Advanced management of this disease has contributed to making Italian transplant medicine a worldwide reference point, also thanks to the organized network for cystic fibrosis care. This network is founded on Law No. 548 of December 23, 1993, which established regional specialized centers, promoting close collaboration with transplant centers in the management of these patients.
In parallel, advances in thoracic surgery, intensive care, infectious disease medicine and pulmonology have made lung transplantation an increasingly effective therapy even for patients with endstage lung diseases associated with significant comorbidities. These include HIV infection, with the first double lung transplant in an HIVpositive patient performed on May 25, 2007 at ISMETT in Palermo by Bruno Gridelli, and respiratory failure due to COVID-19, for which Mario Nosotti performed the world’s first lung transplant in Milan in 2020. In addition, in 2021 Michele Colledan performed the first sequential bilateral lung transplantation from a donor who had previously had COVID-19 pneumonia 94,95.
In recent years, technological innovation has played a crucial role, particularly with the introduction of ex-vivo lung perfusion (EVLP). This technique allows lungs to be maintained and evaluated outside the human body, improving their quality prior to transplantation and enabling the use of organs that would previously have been considered unsuitable. The lung field represented the first area of application of machine perfusion technologies, which were subsequently extended to other organs.
In Italy, EVLP was introduced early, with the first transplant of reconditioned lungs performed in 2011 at the Policlinico of Milan. During the same period, the Padua center, under the leadership of Federico Rea (Fig. 31), participated as the only Italian center in the INSPIRE study, the first multicentric randomized trial comparing cold storage with portable normothermic perfusion using the Organ Care System Lung device.
These achievements have enabled Italian centers to assume a leading role as opinion leaders in numerous international consensus processes, culminating in 2025 with the publication of the first national consensus on the use of perfusion machines in lung transplantation.
Further progress has been achieved in the field of donation, with the first lung transplant from a living donor in Italy performed in January 2023 in Bergamo 96 and, most importantly, with the introduction of DCD, a fundamental resource for increasing organ availability. Since the first lung transplant from a DCD donor in November 2014, major milestones have been reached, including the development of a specific ventilation protocol for class II DCD donors, now adopted internationally in place of the previous topical thoracic cooling system.
At the same time, the expansion of class III DCD donors, combined with cardiac donation through prolonged TANRP due to Italian 20 minute “notouch” period, has renewed international attention on Italian lung transplantation thanks to the results of the national multicenter experience.
The establishment of national programs represents the most recent development in Italian lung transplantation. These include the sharing of clinical protocols, such as the Emergenze program (launched in 2010 and subsequently revised), the introduction of allocation based on the Lung Allocation Score in 2025, and the activation of training and scientific research programs within the Italian Society of Organ Transplantation, including the establishment, in November 2024, in Florence, of the first Academy on Lung Transplantation.
In conclusion, over little more than thirty years, lung transplantation in Italy has evolved from an experimental procedure to a consolidated and highly effective clinical reality. Through the integration of scientific research, technological innovation, and healthcare organization, it now represents a concrete lifesaving option for numerous patients with severe lung diseases and continues to evolve toward increasingly improved outcomes.
UTERUS TRANSPLANTATION
Uterus transplantation is a purpose-oriented transplantation procedure aimed at enabling women with absolute uterine factor infertility to achieve pregnancy and childbirth. Once reproductive function has been achieved, the transplanted uterus may be surgically removed, allowing discontinuation of immunosuppressive therapy.
To date, uterus transplantation in Italy has been performed exclusively in Catania, through the collaboration between Paolo Scollo (gynecologist at Cannizzaro Hospital) and Pierfrancesco Veroux (Fig. 32). (transplant surgeon at the Transplant Center of the Azienda Policlinico San Marco in Catania). The initial procedures were made possible by an experimental protocol approved by the Centro Nazionale Trapianti (CNT) in 2018 and implemented in 2020.
The first uterus transplant was performed on 23 August 2020 in a 30-year-old Sicilian woman affected by Mayer-Rokitansky-Küster-Hauser syndrome, using a graft donated by a 38-year-old woman from Tuscany. The procedure was fully successful, leading to the birth of a child, Alessandra, on 30 August 2022, named in honor of the donor. This was the first birth in Italy following uterus transplantation and the sixth reported worldwide.
Subsequently, three additional uterus transplants were performed, resulting in the birth of another child in September 2025. Both children are in excellent health, as are all recipients. Two grafts were removed due to rejection, one graft was explanted after successful pregnancy, while one graft remains currently functional 97,98.
ORGAN TRANSPLANTATION FROM DONORS WITH INFECTIONS
In 2001, the CNT, the authority overseeing all transplant activities, established a national commission of multidisciplinary experts in accordance with Italian Law 91/99. The aim was to develop national guidelines for the evaluation of potential organ donors. In September 2003, these guidelines were approved by the CNT as a technical annex to the Ministerial Decree of 2 August 2002. In November 2003, they were formally endorsed by the State-Regions Conference between the Ministry of Health and the Regional Health Authorities 99. The guidelines have since been periodically updated, with the most recent version issued in January 2024 100. In parallel, the CNT established an expert “second-opinion” task force to support the transplant network in the assessment of marginal donors. This panel, composed of specialists appointed by Ministerial Decree of 27 October 2004 and subsequently reconfirmed by CNT directives 101, provides centralized expert evaluation of complex donor cases.
Paolo Grossi, from Varese, has been a leading figure of the group responsible for evaluating donors with infectious conditions and has also served, since its inception, as coordinator of the Council of Europe guidelines on the quality and safety of organs for transplantation 102,103.
CONCLUSIONS
The authors, while expressing their gratitude to all contributors, acknowledge that this reconstruction may have certain limitations. These may be related to the inherent difficulty in accurately retracing all transplant pathways across Italian centers, both because some of the key protagonists or direct witnesses are no longer available over time, and because clinical advances were not always promptly published in scientific journals, particularly in earlier decades. Moreover, until the 1980s, Italian surgeons sometimes published their work in local Italian-language journals that are no longer easily traceable today. This was the case, for example, for the first experimental canine liver transplantation performed by Vittorio Staudacher in 1952, which was previously erroneously attributed to C. Stuart Welch (heterotopic transplantation, 1955) and Jack Cannon (orthotopic transplantation, 1955), since the 1952 publication appeared in Italian and in a journal not indexed in widely used scientific databases 44.
That said, we believe that this reconstruction adequately reflects the history of transplantation in Italy, particularly in its overall essence and trajectory (Tab. I). Starting from pioneering and sometimes anecdotal experiences, also influenced by the limited availability of effective contemporary medical therapies, the field progressively evolved into a highly developed and richly articulated system, expressing a level of excellence that is currently unmatched worldwide. This journey has certainly been long and often challenging, but also highly stimulating, as each initial obstacle was followed by clinical progress and success.
Opening a window onto the most promising future perspective in transplantation is likely represented by xenotransplantation. Looking beyond the concept of using animal organs for transplantation in a framework like allotransplantation (and therefore still requiring immunosuppression and anti-infective prophylaxis), xenotransplantation, driven by advances in genetic engineering, may eventually provide organs compatible with specific recipients without the need for immunosuppression. The current paradigm, in which the recipient is modified to accept the graft, would thus shift toward the ability to modify the donor organ so that it becomes compatible with a specific recipient. In addition, xenotransplantation could provide a potentially unlimited supply of organs, overcoming the long-standing barrier of organ shortage that has historically limited the therapeutic reach of transplantation. When this becomes reality, the entire journey may be seen as a full circle, returning to the pioneering and visionary xenotransplantation attempt performed in 1966 by Prof. Paride Stefanini. Indeed, in medicine, major contemporary innovations often have their roots in early visionary insights that only later become feasible through technological progress.
History
Received: May 2, 2026
Accepted: May 2, 2026
Figures and tables
Figure 1. Pope Saint John Paul II meets Prof. Raffaello Cortesini at the 18th World Transplant Congress held in Rome in 2000.
Figure 2. Prof. Paride Stefanini in the 1960s. Prof. Stefanini, founder of SITO, is considered the father of organ transplantation in Italy.
Figure 3. From right to left: Prof. Casciani, Prof. Stefanini, Prof. Cortesini, and Prof. Arullani.
Figure 4. Prof. Giorgio Ribotta, who performed the first living-donor nephrectomy in Italy.
Figure 5. The recipient of the renal xenograft from a chimpanzee in the early postoperative recovery period.
Figure 6. The team that performed the first laparoscopic living-donor nephrectomy and the associated kidney transplantation on 27 April 2000. First and second from the right: Fabio Vistoli and Ugo Boggi (wearing a surgical mask); fourth from the right: Andrea Pietrabissa.
Figure 7. Ugo Boggi (Pisa). For many years, Ugo Boggi directed the kidney and pancreas transplantation programs in Pisa and, together with Franco Filipponi under the leadership of Franco Mosca, established the liver transplantation program in Pisa. His distinguished contributions to the history of organ transplantation in Italy include Europe’s first simultaneous kidney transplantation from a living donor and pancreas transplantation from a deceased donor (2001); the introduction of kidney paired exchange in Italy (2005); fully robotic living-donor nephrectomy (2008); single-incision laparoscopic living-donor nephrectomy (2010); Europe’s first robotic kidney transplantation (2010); the world’s first robotic pancreas transplantation (2010); the world’s first robotic simultaneous pancreas–kidney transplantation (2010); laparoscopic living-donor left lateral segmentectomy for adult-to-child liver transplantation (2010); the world’s first fully robotic living-donor right hepatectomy for adult-to-adult liver transplantation (2012); and laparoscopic renal autotransplantation (2015). Ugo Boggi also performed most pancreas-alone transplantations carried out in Italy, organized the world’s first (and, to date, only) consensus conference on pancreas transplantation, subsequently publishing the resulting guidelines, and chaired the 20th World Congress of the International Pancreas and Islet Transplant Association (IPITA).
Figure 8. The Italian State Police Lamborghini Huracán in the foreground, as officers deliver a kidney intended for transplantation, in the context of one of the kidney paired exchange (cross-over) donation-transplant chains initiated in Italy following the landmark procedure performed in Pisa on 15 November 2005.
Figure 9. Ugo Boggi (second from the right) at the First World Consensus Conference on Minimally Invasive Organ Transplantation, held in Riyadh (Saudi Arabia), December 12-14, 2024. The other surgeons in the picture, from right to left, are Giuliano Testa (Dallas, Texas, USA), Mario Spaggiari (Chicago, Illinois, USA), Philippe Abreu (Denver, Colorado, USA), and Ivo Tzvetanov (Chicago, Illinois, USA).
Figure 10. Luisa Berardinelli (Milan-Policlinico), the first woman to perform an organ transplantation in Italy (1979), during the award ceremony at the 44th National Congress of SITO (Italian Society of Organ Transplantation), Naples, 3 October 2021.
Figure 11. Cover of the Bollettino Medico Chirurgico Pisano, October-December 1967, Volume XXXV, Number 4, featuring the article on experimental pancreatoduodenal transplantation in the canine model performed in Pisa.
Figure 12. Luciano Gregorio De Carlis (Milan-Niguarda Hospital). For many years, Prof. De Carlis directed the liver, pancreas, and kidney transplantation programs at Niguarda Hospital in Milan. His distinguished contributions to the history of organ transplantation in Italy include adult living-donor liver transplantation (2001), combined liver–pancreas transplantation (2004), hand-assisted robotic living-donor nephrectomy (2008), and liver transplantation from donation after circulatory death (2015).
Figure 13. Ugo Boggi (surgeon) on the left and Giovanni Consani (anesthesiologist) preparing to toast the completion of the world’s first robotic pancreas transplantation (27 September 2010).
Figure 14. Opening ceremony of the 20th IPITA Congress in Pisa. On the stage, Ugo Boggi; in the background, a commemorative image of David E.R. Sutherland.
Figure 15. Ugo Boggi (Pisa) on the right and Jonathan Fridell (Indianapolis, USA) at the first world consensus conference on pancreas transplantation.
Figure 16. Raffaello Cortesini (Rome-Policlinico Umberto I). Raffaello Cortesini, a disciple of Paride Stefanini, made fundamental contributions to the early development of abdominal organ transplantation in Italy. He personally performed the first simultaneous kidney and pancreas transplantation (1981), followed by the first liver transplantation (1982) and the first multivisceral abdominal transplantation (1989). Prof. Cortesini also organized the 18th World Congress of The Transplantation Society (TTS) in Rome in 2000.
Figure 17. Dinangelo Galmarini (Milan-Policlinico). Dinangelo Galmarini established Italy’s second liver transplantation program in Milan in 1983.
Figure 18. Giuseppe Gozzetti (Bologna). Giuseppe Gozzetti was one of the most dynamic and influential surgeons in the field of liver surgery and transplantation during the 1980s and 1990s. In Bologna, he established a training school of international relevance in this field.
Figure 19. Lino Belli (Milan-Niguarda Hospital). Lino Belli initiated the liver transplantation program at the Niguarda Hospital in Milan in 1986. His surgical school, one of the most prominent in Italy, was subsequently continued by Luciano Gregorio De Carlis.
Figure 20. Umberto Valente (Genoa) during a humanitarian mission in Madagascar. Umberto Valente initiated the liver transplantation program in Genoa in 1986, where he was also responsible for kidney and pancreas transplantation.
Figure 21. Mauro Salizzoni and Renato Romagnoli celebrating the 4,000th liver transplantation in Turin on 25 November 2023. The main contribution of the Turin surgical group was to demonstrate that many organs previously considered unsuitable for transplantation could, in fact, be successfully used. This broadened donor selection criteria and substantially increased organ availability. The center has performed liver transplantation in both adult and pediatric recipients, with a predominance of adult cases. As a result of this approach, the Turin liver transplant center has performed the highest number of liver transplants in Italy.
Figure 22. Davide D’Amico (Padua) in the foreground. The father of the transplanted child shakes hands with His Holiness Pope John Paul II. Davide D’Amico performed the first living-donor pediatric liver transplantation and the first living-donor segmental liver transplantation in Italy. He established in Padua one of the leading Italian centers for liver surgery and transplantation, developing a highly influential surgical school in the field.
Figure 23. Eugenio Santoro (Rome-San Camillo) (on the left) receiving the Gold Medal for Meritorious Service in Public Health from the President of the Italian Republic, Carlo Azeglio Ciampi. The award was granted to Prof. Santoro for successfully performing the first liver transplantation in an HIV-positive recipient.
Figure 24. Intestinal graft on the back table (courtesy of Michele Colledan).
Figure 25. Multivisceral graft on the back table (courtesy of Michele Colledan).
Figure 26. Luigi Donato (CNR-Pisa), who launched the Italian National Heart Transplant Programme and served for many years as Chair of the Ministry of Health Committee for Cardiology and Cardiac Surgery. Prof. Donato also promoted early studies on the artificial heart in Italy (ICARUS project).
Figure 27. Vittorio Staudacher, who performed the world’s first experimental liver transplantation in 1952 and the first heart–lung transplantation in Italy in 1983 (the recipient did not survive).
Figure 28. Vincenzo Gallucci (Padua), who performed the first successful heart transplantation in Italy during the night of 13-14 November 1985. The recipient married 20 months later and survived for almost seven years after transplantation, enjoying a near-normal quality of life.
Figure 29. Mario Viganò (Pavia), who performed in Italy the second heart transplantation (1985), the first domino heart transplantation (1987), and the first successful en-bloc heart–lung transplantation (1991).
Figure 30. Francesco Crucitti (Rome-Policlinico Gemelli), who conducted pioneering experimental studies on lung transplantation in the 1960s and performed one of the first lung transplantations in Italy in 1993. In this photograph, Prof. Crucitti, wearing a white coat, is seen alongside His Holiness Pope John Paul II.
Figure 31. Federico Rea (Padua), a pioneer of lung transplantation in Italy and an outstanding innovator, particularly in the development and clinical implementation of portable normothermic perfusion techniques.
Figure 32. Pierfrancesco Veroux (surgeon, left) and Paolo Scollo (gynecologist, right) at the baptism of the first child born in Italy following uterus transplantation.
| Event | Center | Year | Pioneers | Outcome |
|---|---|---|---|---|
| KIDNEY | ||||
| Deceased donor kidney transplant | Rome - Policlinico Umberto I | 1966 | Pietro Valdoni | Unsuccessful |
| Live donor nephrectomy (open) | L’Aquila | 1966 | Giorgio Ribotta | Successful |
| Live donor kidney transplant | Rome - Policlinico Umberto I | 1966 | Paride Stefanini | Successful |
| Xenotransplant (chimpanzee to man) | Rome - Policlinico Umberto I | 1966 | Paride Stefanini | Successful |
| Deceased donor kidney transplant | Bologna | 1967 | Aldo Martelli | Successful |
| Renal transplant by a woman surgeon | Milan - Policlinico | 1979 | Luisa Berardinelli | Successful |
| Dual kidney transplantation | Bergamo | 1997 | Giuseppe Remuzzi | Successful |
| Live donor laparoscopic nephrectomy | Pisa | 2000 | Andrea Pietrabissa | Successful |
| Kidney transplantation in an HIV-positive recipient | Palermo - ISMETT | 2001 | Ignazio Marino | Successful |
| Kidney paired exchange | Pisa | 2005 | Ugo Boggi | Successful |
| Live donor robotic nephrectomy | Pisa | 2008 | Ugo Boggi | Successful |
| Hand-assisted live donor robotic nephrectomy | Milan - Niguarda | 2008 | Luciano Gregorio De Carlis | Successful |
| AB0 incompatible renal transplantation | Parma | 2008 | Enzo Capocasale | Successful |
| Deceased donor renal transplant after circulatory death | Pavia | 2008 | Massimo Abelli | Successful |
| Single incision laparoscopic living donor nephrectomy | Pisa | 2010 | Ugo Boggi | Successful |
| Robotic renal transplantation | Pisa | 2010 | Ugo Boggi | Successful |
| Peri-transplant infusion of autologous bone marrow-derived mesenchymal stromal cells | Bergamo | 2011 | Giuseppe Remuzzi | Successful |
| Laparoscopic renal autotransplantation | Pisa | 2015 | Ugo Boggi | Successful |
| Samaritan donation | Pavia | 2015 | Andrea Pietrabissa | Successful |
| Kidney domino exchange chains initiated by deceased-donor donation (DEC-K) | Padua | 2018 | Lucrezia Furian | Successful |
| PANCREAS | ||||
| Simultaneous pancreas and kidney transplant | Rome - Policlinico Umberto I | 1981 | Raffaello Cortesini | Successful |
| Simultaneous kidney transplantation from a living donor and pancreas transplantation from a deceased donor | Pisa | 2001 | Ugo Boggi | Successful |
| Liver-pancreas combined transplant | Milan - Niguarda | 2004 | Luciano Gregorio De Carlis | Successful |
| Simultaneous pancreas and kidney transplant in HIV-positive recipients | Varese | 2006 | Ugo Boggi and Renzo Dionigi | Successful |
| Robotic pancreas transplant | Pisa | 2010 | Ugo Boggi | Successful |
| Robotic simultaneous pancreas and kidney transplant | Pisa | 2010 | Ugo Boggi | Successful |
| ISLET CELL TRANSPLANTATION | ||||
| Islet transplantation with insulin independence | St. Louis | 1989 | Piero Marchetti | Temporarily successful |
| Kidney-islet transplantation | Cagliari (with islet prepared in Perugia) | 1989 | Riccardo Calafiore | Temporarily successful |
| Islet transplantation | Milan – San Raffaele Hospital | 1989 | Guido Pozza and Antonio Secchi | Temporarily successful |
| Transplantation of microencapsulated islets without immunosuppression | Cagliari (islet prepared in Perugia) | 1989 | Riccardo Calafiore | Temporarily successful |
| Intraperitoneal transplantation of microencapsulated islets without immunosuppression | Perugia | 2003 | Riccardo Calafiore | Temporarily successful |
| LIVER | ||||
| Adult liver transplantation | Rome - Policlinico Umberto I | 1982 | Raffaello Cortesini | Successful |
| Pediatric liver transplantation | Milan - Policlinico | 1988 | Bruno Gridelli | Successful |
| Pediatric living donor liver transplantation | Padua | 1997 | Davide D’Amico and Koichi Tanaka | Successful |
| Deceased donor split liver transplantation for two adult recipients | Bergamo | 1999 | Michele Colledan | Successful |
| Liver autotransplantation | Varese | 1999 | Renzo Dionigi | Successful |
| Adult living donor liver transplantation | Milan - Niguarda | 2001 | Luciano Gregorio de Carlis | Successful |
| Liver transplantation in an HIV-positive recipient | Rome - Istituto Tumori Regina Elena | 2002 | Eugenio Santoro | Successful |
| Liver-lung transplantation | Bergamo | 2002 | Bruno Gridelli and Michele Colledan | Successful |
| Segmental living donor liver transplantation | Padua | 2004 | Davide D’Amico and Koichi Tanaka | Successful |
| Liver transplantation after circulatory death | Pisa | 2005 | Franco Filipponi | Unsuccessful |
| Auxillary liver transplantation | Padua | 2007 | Umberto Cillo | Successful |
| Laparoscopic living donor left lateral segmentectomy (adult-to-child liver transplantation) | Palermo - ISMETT | 2010 | Ugo Boggi | Successful |
| Fully robotic living donor right hepatectomy (adult-to-adult liver transplantation) | Palermo - ISMETT | 2012 | Ugo Boggi | Successful |
| Liver transplantation after circulatory death | Milan - Niguarda | 2015 | Luciano Gregorio de Carlis | Successful |
| RAPID (Resection And Partial Liver segment II-III transplantation with Delayed total hepatectomy) | Padua | 2019 | Umberto Cillo | Successful |
| Adult liver transplantation from SARS-CoV-2 positive donor | Palermo - ISMETT | 2020 | Salvatore Gruttadauria | Successful |
| Pediatric liver transplantation from SARS-CoV-2 positive donor | Turin | 2020 | Renato Romagnoli | Successful |
| Dual-graft living donor liver transplantation | Padua | 2023 | Umberto Cillo | Successful |
| Full-size robotic liver transplantation | Modena | 2024 | Fabrizio Di Benedetto | Successful |
| Right lobe robotic liver transplantation | Modena | 2025 | Fabrizio Di Benedetto | Successful |
| INTESTINAL AND MULTIVISCERAL | ||||
| Multivisceral transplantation (adult) | Rome - Policlinico Umberto I | 1989 | Raffaello Cortesini | Successful |
| Liver-bowel (pediatric) | Bergamo | 1999 | Bruno Gridelli | Successful |
| Isolated small bowel (adult) | Modena | 2000 | Antonio Daniele Pinna | Successful |
| Isolated small bowel (pediatric) | Bergamo | 2006 | Michele Colledan | Successful |
| Multivisceral transplantation (pediatric) | Bergamo | 2006 | Michele Colledan | Successful |
| Living donor liver-small bowel transplantation (pediatric) | Bergamo | 2010 | Michele Colledan | Successful |
| HEART (Including heat-lung) | ||||
| Heart-lung transplantation | Milan - Policlinico | 1983 | Vittorio Staudacher | Unsuccessful |
| Heart transplantation (adult) | Padua | 1985 | Vincenzo Gallucci | Successful |
| Heart transplantation (pediatric) | Rome - Policlinico Umberto I | 1986 | Benedetto Marino and Michele Toscano | Successful |
| Heart-kidney transplantation | Padua | 1986 | Vincenzo Gallucci and Tommaso Tommaseo Ponzetta | Successful |
| Artificial heart implantation (adult) | Pavia | 1987 | Mario Viganò | Successful |
| Heart-liver transplantation | Bologna | 1987 | Giorgio Arpesella and Giuseppe Gozzetti | Successful |
| Heart transplantation (neonate) | Padua | 1987 | Vincenzo Gallucci | Successful |
| Domino heart transplantation | Pavia | 1987 | Mario Viganò | Successful |
| Heart-lung transplantation | Pavia | 1991 | Mario Viganò | Successful |
| AB0-incompatible heart transplantation (pediatric) | Padua | 2006 | Gino Gerosa | Successful |
| Ex vivo cardiac perfusion | Udine | 2007 | Ugolino Livi | Successful |
| Artificial heart implantation (pediatric) | Rome - Bambino Gesù | 2010 | Antonio Amodeo | Successful |
| Heart transplantation after circulatory death | Padua | 2019 | Gino Gerosa | Successful |
| Beating-heart transplant from a brain-dead donor | Udine | 2024 | Igor Vendramin | Successful |
| Beating-heart transplant after circulatory death | Padua | 2024 | Gino Gerosa | Successful |
| LUNG | ||||
| Lung transplantation (adult) | Rome - Policlinico Umberto I | 1991 | Costante Ricci | Successful |
| Bilateral lung transplantation (pediatric) | Bergamo | 2004 | Michele Colledan | Successful |
| Double lung transplantation in HIV-positive recipient | Palermo - ISMETT | 2007 | Bruno Gridelli | Successful |
| Ex-vivo lung perfusion | Milan - Policlinico | 2011 | Luciano Gregorio Gattinoni | Successful |
| Double lung transplantation in a recipient with lung failure due to SARS-CoV-2 infection | Milan - Policlinico | 2020 | Mario Nosotti | Successful |
| Bilateral lung transplantation from a donor with previous severe COVID-19 pneumonia | Bergamo | 2021 | Michele Colledan | Successful |
| Living donor lung transplantation (pediatric) | Bergamo | 2023 | Michele Colledan | Successful |
| UTERUS | ||||
| Uterus transplantation (deceased donor) | Catania | 2020 | Pierfrancesco Veroux and Paolo Scollo | Successful (live birth) |
