Comparison of < 100 cc prostates and > 100 cc prostates undergoing aquablation for benign prostatic hyperplasia

Minimally invasive surgical therapies (MISTs) for lower urinary tract symptoms (LUTS): promise or panacea?

ABSTRACT

The increasing importance of treatment of lower urinary tract symptoms (LUTS), while avoiding side effects and maintaining sexual function, has allowed for the development of minimally invasive surgical therapies (MISTs). Recently, the European Association of Urology guidelines reported a paradigm shift from the management of benign prostatic hyperplasia (BPH) to the management of nonneurogenic male LUTS. The aim of the present review was to evaluate the efficacy and safety of the most commonly used MISTs: ablative techniques such as aquablation, prostatic artery embolization, water vapor energy, and transperineal prostate laser ablation, and nonablative techniques such as prostatic urethral lift and temporarily implanted nitinol device (iTIND). MISTs are becoming a new promise, even if clinical trials with longer follow-up are still lacking. Most of them are still under investigation and, to date, only a few options have been given as a recommendation for use. They cannot be considered as standard of care and are not suitable for all patients. Advantages and disadvantages should be underlined, without forgetting our objective: treatment of LUTS and re-treatment avoidance.

Ablative minimally invasive surgical therapies for benign prostatic hyperplasia: A review of Aquablation, Rezum, and transperineal laser prostate ablation

INTRODUCTION

Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting men and can present with bothersome lower urinary tract symptoms (LUTS). Historically, transurethral resection of the prostate (TURP) has been considered the gold standard in the treatment of LUTS due to BPH. However, TURP and other traditional options for the surgical management of LUTS secondary to BPH are associated with high rates of sexual dysfunction. In the past decade, several novel technologies, including Aquablation therapy, convective water vapor therapy (Rezum), and transperineal prostate laser ablation (TPLA), have demonstrated promising evidence to be safe and effective while preserving sexual function.

METHODS

In this review, we discuss three ablative minimally invasive surgeries: Aquablation, Rezum, and TPLA. We review their techniques, safety, as well as perioperative and functional outcomes. We go into further detail regarding sexual function after these ablative minimally invasive surgical therapies.

RESULTS

Aquablation is a surgeon-guided, robot-executed, heat-free ablative waterjet procedure with sustained functional outcomes at 5 years while having no effect on sexual activity. Rezum is an innovative office-based, minimally invasive surgical option for BPH that delivers convective water vapor energy into prostate adenoma to ablate obstructing tissue. Rezum leads to significant improvements in Qmax, IPSS while preserving sexual function. TPLA is another office-based technology which uses a diode laser source to produce thermoablation. It leads to improvement in Qmax, IPSS, and QoL while preserving ejaculatory function.

CONCLUSIONS

Overall, ablative minimally invasive surgical therapies have demonstrated excellent safety and efficacy profiles while preserving sexual function. These modalities should be discussed with patients to ensure informed and shared decision-making. Ablative minimally invasive surgical therapies may be particularly interesting to patients who value the preservation of their sexual function.

Will Aquablation Be the New Benchmark for Robotic Minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia?

BACKGROUND AND OBJECTIVE

Aquablation is included in the European Association Urology guidelines as an alternative surgical technique for prostate resection. The evidence summary states that it is subjectively and objectively as effective as transurethral resection of the prostate (TURP) and enucleation, but concerns remain regarding postoperative bleeding. Our aim was to provide an evidence-based overview of the trials, triumphs, and technical challenges of Aquablation.

METHODS

A literature search in the PubMed, EMBASE, and Scopus databases was performed to identify clinical prospective and retrospective studies and reviews on Aquablation. A total of 54 reports were included. A narrative review of current evidence and an overview of the surgical technique are provided.

KEY FINDINGS AND LIMITATIONS

Aquablation demonstrates excellent short- and long-term functional outcomes, with a good safety profile comparable to that of TURP. The procedure is efficient and safe, even for very large prostates, with sustained improvements in functional outcomes well maintained up to 5 yr. The unique ability to conduct robotically controlled precise ablation of enlarged tissue while maintaining the sphincter makes Aquablation a very good ejaculation-sparing BPH treatment option. Initial issues with hemostasis have been successfully overcome with the use of gentle bladder-neck cautery after the procedure, allowing for early catheter removal. The above features make Aquablation an attractive minimally invasive technique and show that it is noninferior to holmium laser enucleation.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Aquablation is a valid alternative to standard resection techniques, showing excellent long-term functional outcomes, good preservation of sexual function, a good safety profile, and good compliance for all prostate sizes and patient ages. Aquablation is still performed in high-volume centers, but the results can easily be emulated in other centers worldwide.

ADVANCING PRACTICE

Our review indicates that if Aquablation outcomes are emulated globally, this technique could easily become a new benchmark in robotic treatment for BPH.

PATIENT SUMMARY

Aquablation is a safe and effective surgical technique for treatment for benign enlargement of the prostate, with excellent medium-term outcomes. Although long-term studies are needed, the results are promising and challenge the current surgical and laser techniques used to reduce the size of the prostate gland.

Initial Experience Performing "Cautery Free Waterjet Ablation of the Prostate"

Introduction Herein, we describe our initial experience performing waterjet ablation of the prostate without electrocautery. Methods A retrospective review of patients undergoing Aquablation for BPH between February and September 2019 was performed. A standardized perioperative protocol for optimizing hemostasis was implemented. The primary endpoint was to define bleeding complications perioperatively and up to 30 days postoperatively after Aquablation. Bleeding complications included hematuria requiring prolonged continuous bladder irrigation, drop in hemoglobin requiring transfusion, or take back to operating room for evacuation of bladder clots and bladder fulguration. Bivariable analysis using Fisher's exact test and unpaired t-tests were used to identify factors associated with bleeding complications. Results Thirty-two patients underwent Aquablation over the study period. Average preoperative IPSS was 20 (Range: 13 to 34) and Qmax was 7mL/s (Range: 0 to 11). Mean prostate volume was 65 mL (Range: 30 mL to 200 mL). Average perioperative change in hemoglobin was 1.3 g/dL (Range: -0.3 g/dL to 4.2 g/dL). Eight patients (25%) experienced bleeding complications. Three (9.4%) required blood transfusions. On Fisher's exact test, prostate volume (91 mL vs 55 mL; p = 0.0361) and preoperative prostate specific antigen (6.6 vs 2.9; p = 0.0218) were associated with postoperative bleeding. Conclusions Performing waterjet ablation of the prostate without the use of electrocautery after waterjet treatment to control bleeding resulted in significant bleeding complications (25% of our cohort) during our initial experience. A combination of traction and focal bladder neck electrocautery is the best strategy to minimize bleeding complications after Aquablation.

A narrative review of the management of benign prostatic hyperplasia in patients undergoing penile prosthesis surgery

Penile prosthesis surgery is an effective and durable treatment modality for patients who have failed conservative management for erectile dysfunction (ED). Thorough patient counseling and appropriate preoperative workup lay the foundation for a successful outcome. While the risk of infection of penile prosthesis is rare, it is a dreaded complication with dire consequences. The goal of the prosthetic surgeon is to minimize the risk of preventable complications. Given the common prevalence of benign prostatic hyperplasia (BPH) in this patient population, it is essential that providers are familiar with the implications and nuances of managing both conditions in order to maximize the chances of a favorable result. Due to the relatively infrequent nature of complications associated with the management of BPH in the setting of a penile prosthesis, literature regarding this topic is scarce. In this narrative review we present our own case series illustrating some of the most common scenarios that a prosthetic surgeon may encounter. We have included our suggestions for management in these difficult situations based on our clinical experience. In the following review we have highlighted the importance of identifying and treating BPH in penile implant candidates to reduce postoperative morbidity and to offer critical insights into managing BPH-related complications this population.

The combination of waterjet ablation (Aquabeam®) and holmium laser power for treatment of symptomatic benign prostatic hyperplasia: early functional results

Introduction

The aim of this study was to assess the short-term functional outcomes and the efficacy of hemostasis performed with holmium laser performed following prostatic hydroablation with the Aquabeam^® system.

Material and methods

Between June 2019 and July 2020, 53 consecutive patients underwent Aquabeam^® with our modified hemostasis approach with holmium laser. The following standard preoperative assessments were retrospectively recorded: prostate volume; International Prostate Symptom Score (IPSS) and Quality of Life (IPSS-QoL); uroflowmetry including Qmax and post void residual volume (PVR).

Results

Fifty-three patients consecutively underwent aquablation and holmium laser hemostasis. Median age at surgery, median prostate-specific antigen (PSA) and median prostate volume were 62 years (IQR: 57-66), 2.95 ng/ml (IQR: 1.6-4.8) and 55 ml (IQR: 43-65), respectively.Median operative time was 60 minutes (IQR: 40-80). Median catheterization time and length of hospital stay were 2 days (IQR: 1-3) for both parameters. The median hemoglobin decrease between the preoperative values and those assessed on the second day was equal to 1.25 g/dl (IQR: 0.7-1.85).Continence rate was 100% at catheter removal. Thirty-six patients (72%) reported anterograde ejaculation preservation. IPSS (6, 3-21) and Qmax (19, 9-26) changed dramatically between baseline and 3 months follow-up.

Conclusions

The combination of Aquabeam^® and holmium laser energy for hemostasis is a safe, reproducible technique to relieve moderate lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH) while preserving ejaculation in younger and sexually active individuals. The short-term results showed a lower rate of complications; the encouraging functional results confirm that this can be a valid surgical approach for treatment of BPH.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

WATER versus WATER II 2-Year Update: Comparing Aquablation Therapy for Benign Prostatic Hyperplasia in 30-80-cm3 and 80-150-cm3 Prostates

Background

Surgical options are limited when treating large (>80 cm³) prostates for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Open simple prostatectomy remains the most common procedure performed for large prostates. There is a need for novel surgical approaches with shorter learning curves and effective treatment. Aquablation could be this novel tool.

Objective

To compare the outcome of Aquablation for 30-80-cm³ prostates with the outcome for 80-150-cm³ prostates at 2-yr follow-up.

Design setting and participants

We used data from two trials. WATER is a prospective, double-blind, multicenter, international clinical trial comparing the safety and efficacy of Aquablation and transurethral resection of the prostate in the treatment of LUTS/BPH in men aged 45-80 yr with a prostate of 30-80 cm³. WATER II is a prospective, multicenter, single-arm international clinical trial of Aquablation in men with a prostate of 80-150 cm³.

Intervention

Aquablation, an ultrasound-guided, robotically executed waterjet ablative procedure.

Outcome measurements and statistical analysis

We compared 24-mo outcomes between 116 WATER and 101 WATER II study subjects. Student's t test or a Wilcoxon test was used to compare continuous variables and Fisher's test for categorical variables.

Results and limitations

The International Prostate Symptom Score (IPSS) reductions at 24 mo was 14.5 points for WATER and 17.4 points for WATER II (p = 0.31). At baseline, the maximum urinary flow rate (Q_max) was 9.4 and 8.7 cm³/s in WATER and WATER II, improving to 20.5 and 18.2 cm³/s, respectively (p = 0.60) at 24 mo. Improvements in both IPSS and Q_max were immediate and sustained throughout follow-up. At 2 yr, the surgical retreatment rate was 4% in WATER and 2% in WATER II.

Conclusions

Aquablation is effective in patients with a prostate of 30-80 cm³ and patients with a prostate of 80-150 cm³ treated for LUTS/BPH, with comparable outcomes in both groups. It has low complication and retreatment rates at 2 yr of follow-up, with durable improvements in functional outcome.

Patient summary

Outcomes of Aquablation for both small-to-moderately-sized and large prostates are similar and sustainable at 2 yr of follow-up.

Which Anatomic Structures Should Be Preserved During Aquablation Contour Planning to Optimize Ejaculatory Function? A Case-control Study Using Ultrasound Video Recordings to Identify Surgical Predictors of Postoperative Anejaculation

OBJECTIVE

To identify key anatomic structures that should be preserved to decrease postoperative anejaculation after Aquablation.

METHODS

We conducted a case-control study design using patient data and operative video logs from Aquablation clinical trials. Cases were sexually active participants with functional baseline ejaculation and postoperative anejaculation. Controls were sexually active participants with functional baseline ejaculation and no postoperative decline in sexual function. Each case was matched to 1 or 2 controls. Video logs from the procedure were scored for: verumontanum cut coverage, penetration of ejaculatory ducts, depth of cut below the verumontanum, angle offset of verumontanum to centerline of protection zone, number of passes, and intraprostatic calcifications. Conditional logistic regression was used to calculate univariate odds ratios relating anatomic findings to case/control status.

RESULTS

We identified 24 cases and 27 controls. In univariate analysis, predictors of postoperative anejaculation were: penetration of the ejaculatory ducts (odds ratio [OR] 8.6 [95% CI 1.09-67.5], P = .041) and depth below the verumontanum (OR 1.92 [1.1-3.3], P = .015).

CONCLUSION

Violation of anatomic structures involved in ejaculation during the Aquablation procedure increases the risk of postoperative anejaculation. More careful attention to these structures during contour planning may further improve ejaculatory function after Aquablation.

A Systematic Review of Reported Ejaculatory Dysfunction in Clinical Trials Evaluating Minimally Invasive Treatment Modalities for BPH

PURPOSE OF REVIEW

To explore the sexual outcomes following the novel minimally invasive surgical procedures for benign prostatic hyperplasia- (BPH-) related lower urinary tract symptoms (LUTS), with an emphasis on ejaculatory dysfunction (EjD).

RECENT FINDINGS

A database search with a 10-year time restriction was carried out until February 20, 2020 using MEDLINE through the PubMed Platform evaluating minimally invasive treatment modalities for BPH and their effect on EjD. After the article selection, we retrieved data for men randomized in 19 different studies with results in 40 separate published articles investigating minimally invasive BPH surgery and reporting EjD rates. To date, water vapor thermal therapy or Rezūm, prostatic urethral lift (PUL) or UroLift®, prostate artery embolization (PAE), and Aquablation showed acceptable rates (< 2%) of retrograde ejaculation by 1 year and had very low adverse events related to the procedure. Both PUL and Rezūm demonstrated lower rates when compared with PAE and Aquablation. With comparable sexual side effect profiles postoperatively, clinicians may determine which therapeutic modality is optimal for patients based on efficacy and cost-benefit. Further randomized clinical trials are required to directly compare the effect of novel minimally invasive surgical procedures for BPH-related LUTS on ejaculation and sexual function.

Prostatic Artery Embolization and Sexual Function: Literature Review and Comparison to Other Urologic Interventions

Many interventions to treat men with benign prostatic hyperplasia (BPH) associated lower urinary tract symptoms (LUTS) are associated with sexual side effects or complications, such as hematospermia, erectile dysfunction, or ejaculatory dysfunction. As loss of sexual function can significantly impact quality of life, an optimal treatment for BPH associated LUTS would be one without any sexual dysfunction side effects. Prostatic artery embolization is a minimally invasive treatment for men with BPH associated LUTS. The aim of this paper is to review the effects of prostatic artery embolization on sexual function and compare the sexual side effect profile to the other available BPH procedures.

[A (new) revolution in the treatment of benign prostatic hyperplasia? Aqua-ablation and prostate embolization]

Surgical treatment of benign prostatic obstruction (BPO) is one of the most common procedures in urology. Numerous alternative methods have been developed in recent years to overcome the potential limitations of transurethral resection of the prostate (TURP) while providing comparable effectiveness and less morbidity. In a randomized study with a currently available follow-up of 3 years, the Aquabeam® system has shown comparable functional results with a lower rate of adverse events compared to TURP. Sufficient functional results were also found in a cohort study in patients with prostate volumes up to 150 ml. However, the rate of transfusions raises the question of optimal coagulation. Further cohort studies with short-term follow-up confirmed the results of the randomized studies. Prostate artery embolization (PAE) has been compared to TURP in several randomized trials. In randomized studies, the reduction of BPO-associated symptoms after PAE is only slightly inferior to that after TURP. In contrast, the improvement of functional parameters after embolization is inferior to that after TURP. This is primarily due to the inferior desobstruction. In addition, long-term results from randomized studies are lacking, so that no final assessment has yet been possible with regard to the durability of the desobstruction. In summary, both Aquabeam® and PAE are potential alternatives to standard methods, which-in case of adequate patient selection-can supplement the operative armamentarium in the wider concept of an individualized therapy of BPO.

Patient Perspectives on Benign Prostatic Hyperplasia Surgery: A Focus on Sexual Health

BACKGROUND

In the last decade, many novel minimally invasive surgical techniques within benign prostatic hyperplasia (BPH) surgery were developed to reduce postoperative complications that often discourage patients from pursuing BPH surgery.

AIM

To assess perspective of future and past international BPH surgery patients regarding their postoperative complications, namely erectile and ejaculatory function.

METHODS

A survey was distributed randomly to 2 groups of BPH patients: one with 149 patients having undergone surgery in the last 2 years (group A), and the other cohort of 151 men seriously considering BPH surgery in the next year (group B). This survey consisted of 20 questions that assessed patients' motivating factors for undergoing elective BPH surgery and their perspectives regarding the potential postoperative complications attributed to BPH surgery.

OUTCOMES

The perspective of future and past international BPH surgical patients towards the preservation of their erectile and ejaculatory functions was assessed with the help of a survey.

RESULTS

Results indicated that in general BPH surgery patients considered the maintenance of erectile (95%, n = 284) and ejaculatory function (92%, n = 276) to be important preoperative considerations, regardless of their age. Patients aged 50-59 years were most concerned with the permanent impact on sexual function and patients aged >60 years were most concerned with urinary incontinence. In patients aged >70 years, 66% (n = 43) and 62% (n = 40) of the respondents indicated that maintaining erectile and ejaculatory function was important, respectively.

CLINICAL IMPLICATIONS

Patient-centered care needs to be implemented in order to address the importance that past and future BPH surgery patients hold toward the maintenance of their postoperative sexual function.

STRENGTHS & LIMITATIONS

In the group of patients having previously undergone BPH surgery, the possibility of recall bias should be taken into account when interpreting the study's findings. However, maintaining sexual function was also important for the group of patients seriously considering surgery in the next year suggesting that these considerations are not solely due to recall bias. Additionally, the results were limited by the small sample size of participants in groups A (n = 149) and B (n = 151).

CONCLUSION

It was found that past and future BPH surgery patients attribute a significant importance toward the maintenance of their sexual function. Although novel approaches with better sexual outcomes such as Rezum and UroLift for prostates <80 mL, and Aquablation for any size prostate are available, more research is needed to investigate their long-term effects on sexual function before they can be recommended to patients. Bouhadana D, Nguyen D-D, Zorn KC, et al. Patient Perspectives on Benign Prostatic Hyperplasia Surgery: A Focus on Sexual Health. J Sex Med 2020;17:2108-2112.

Reasons to overthrow TURP: bring on Aquablation

PURPOSE

In this review, we will discuss the state of the literature regarding Aquablation, its limitations, and opportunities for its application in the treatment of benign prostatic enlargement (BPE).

METHODS

A comprehensive review of original research on Aquablation was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, greenlight photoselective vaporization of the prostate, and simple prostatectomy were reviewed for discussion.

RESULTS

For small-medium prostates (30-80 mL), Aquablation's main advantages include better ejaculatory function and similar functional outcomes compared to TURP. For large prostates (80-150 mL), Aquablation demonstrates shorter operative time and superior ejaculatory function when compared to simple prostatectomy, HoLEP, and Greenlight PVP. In addition, Aquablation displays shorter hospital stays than simple prostatectomy. The integration of software programming and semi-automatic technology increases the reproducibility of the procedure and helps standardize overall outcomes, while also accelerating the learning curve. Its ability to preserve antegrade ejaculation makes Aquablation a very compelling option for sexually active patients. However cost and postoperative bleeding risks remain a concern.

CONCLUSION

The current evidence suggests that Aquablation is a safe and effective alternative for BPE for small to large prostates. Further prospective clinical trials, with comparisons to other BPE modalities, and data from longer follow-up periods are still required.

The New American Urological Association Benign Prostatic Hyperplasia Clinical Guidelines: 2019 Update

PURPOSE OF REVIEW

The goal of this paper was to analyze the efficacy of the current modalities available to surgically treat lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

RECENT FINDINGS

There have been significant surgical advancements for the treatment of BPH, including an increasing development and utilization of minimally invasive surgical techniques (MISTs). These procedures have varying outcomes that are critical to understand. In addition, MISTs have important adverse effects, though have minimized effects on sexual function when compared to more invasive surgical techniques. It is important for all urologists to be familiar with the surgical techniques available to treat BPH and the updated American Urological Association (AUA) Guidelines. Further studies evaluating efficacy, safety, and sexual functioning will help guide care in the future and evolve practice.

Operative time comparison of aquablation, greenlight PVP, ThuLEP, GreenLEP, and HoLEP

INTRODUCTION

The BPH surgical armamentarium is composed of a rapidly expanding number of technologies and techniques. These include greenlight photovaporization of the prostate (PVP), greenlight enucleation of the prostate (GreenLEP), holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP) and, more recently, the aquablation procedure. To the best of our knowledge, no direct comparison in operative time has been performed.

METHODS

Data for this study were pooled from five sources. For aquablation, patient-level data from four studies of the aquablation procedure were provided by the device manufacturer as well as from a high-volume commercial user. PVP, GreenLEP, HoLEP, and ThuLEP were performed by high-volume, experienced experts. Endpoints included total operative time, resection time, and proportion of total operative time for resection. General linear models were used to evaluate the relationship between prostate volume (or other continuous predictors) and procedure time.

RESULTS

Total procedure time was related to prostate size. Except for the small prostate size range (size < 40 cc), at any given prostate volume, procedure time was highest for PVP, intermediate for LEPs, and lowest for Aquablation. The relationship between procedure time and prostate size (i.e., slope of the fitted lines) was 0.16 min/g for aquablation, 0.32 min/g, 0.28 min/g and 0.32 min/g for GreenLEP, HoLEP and ThuLEP, respectively, and 0.63 min/g for PVP.

CONCLUSION

In our analysis of pooled data of multi-surgical techniques and technologies, aquablation provided the lowest operative time across all prostate volumes. PVP had the longest procedure time for prostates > 40 cc.

Transfusion rates after 800 Aquablation procedures using various haemostasis methods

OBJECTIVE

To determine if athermal methods are as effective in preventing blood transfusions as the use of cautery across various prostate volumes following prostate tissue resection for benign prostatic hyperplasia using Aquablation.

PATIENTS AND METHODS

The current commercial AQUABEAM robot that performs Aquablation therapy was first used in 2014. Since then numerous clinical studies have been conducted in various countries; Australia, Canada, Germany, India, Lebanon, Spain, New Zealand, United Kingdom, and the United States. All of the clinical trial data since 2014 were pooled with the early commercial procedures from France, Germany, and Spain to determine the effectiveness of haemostatic techniques in reducing the transfusion rate in patients after Aquablation.

RESULTS

In all, 801 patients were treated with Aquablation therapy from 2014 to early 2019. The mean (SD, range) prostate volume was 67 (33, 20-280) mL and 31 (3.9%) transfusions were reported. The largest contributing factor to transfusion risk was prostate size and method of traction. There was an increasing risk of transfusions in larger prostates when robust traction using a catheter-tensioning device (CTD) without cautery was used, ranging from 0.8% to 7.8% in prostates ranging from 20 to 280 mL. However, when standard traction (taping the catheter to the leg, gauze knot synched up to the meatus, or no traction at all) was used and where the surgeon performed bladder neck cautery only when necessary, the risk of transfusion was 1.4-2.5% in prostates ranging from 20 to 280 mL.

CONCLUSIONS

While the athermal subgroup with robust traction with a CTD had comparable transfusion rates for smaller prostates, the risk increased significantly as prostate volume increased. With standard traction methods and selective bladder neck cautery, the risk of transfusion was reduced to 1.9% across all prostate sizes.

Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30-80 and 80-150 mL prostates

Objective

To compare the outcomes of Aquablation in 30–80 mL prostates with those in 80–150 mL prostates. Surgical options, especially with short learning curves, are limited when treating large prostates for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Aquablation (AquaBeam System, PROCEPT BioRobotics Inc., Redwood City, CA, USA) could solve this issue with global reproducibility, independent of prostate volume.

Patients and Methods

Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue (WATER [W‐I]; NCT02505919) is a prospective, double‐blind, multicentre, international clinical trial comparing Aquablation and transurethral resection of the prostate (TURP) for the treatment of LUTS/BPH in prostates between 30 and 80 mL. WATER II (W‐II; NCT03123250) is a prospective, multicentre, single‐arm international clinical trial of Aquablation in prostates between 80 and 150 mL. We compare baseline parameters and 12‐month outcomes in 116 W‐I and 101 W‐II study patients. Students’ t‐test or Wilcoxon tests were used for continuous variables and Fisher’s test for binary variables.

Results

The mean (SD) operative time was 33 (17) and 37 (13) min in W‐I and W‐II, respectively. Actual treatment time was 4 and 8 min in W‐I and W‐II, respectively. The mean change in the International Prostate Symptom Score was substantial averaging (at 12 months) 15.1 in W‐I and 17.1 in W‐II (P = 0.605). By 3 months, Clavien–Dindo grade ≥II events occurred in 19.8% of W‐I patients and 34.7% of W‐II patients (P = 0.468).

Conclusion

Aquablation clinically normalises outcomes between patients with 30–80 mL prostates and patients with 80–150 mL prostates treated for LUTS/BPH, with an expected increase in the risk of complications in larger prostates. Long‐term outcomes of procedure durability are needed.

Efficacy and safety of aquablation of the prostate for patients with symptomatic benign prostatic enlargement: a systematic review

PURPOSE

The aim of this systematic review is to summarize the contemporary literature on aquablation and evaluate its safety and efficacy for the treatment of symptomatic BPE.

EVIDENCE ACQUISITION

A systematic search of English language literature was performed using the PubMed-MEDLINE and Web of Science libraries up to 24 July 2019 by combining PICO (patient population, intervention, comparison, and outcome) terms. We retrieved 16 studies, including 446 patients treated with aquablation eligible for data extraction and analysis. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed.

EVIDENCE SYNTHESIS

We identified a randomized controlled trial (RCT) comparing aquablation to transurethral resection of the prostate (TURP) with 6-month, 1-year, and 2-year outcomes, three single-center and single-arm studies, three multicenter and single-arm studies, and five subgroup analyses. Aquablation significantly improved International Prostate Symptom Score (IPSS), IPSS-quality of life (IPSS-QoL), maximum urinary flow rate (Q_max) and post void residual (PVR) from baseline to last follow-up in all prospective studies. At 2-year follow-up, aquablation showed non-inferior symptom relief compared to TURP, with a lower risk of anejaculation favoring aquablation and no significant differences regarding Clavien-Dindo events. Although a significant hemoglobin drop was reported in all aquablation single-arm studies and when compared to TURP, it did not translate into increased transfusion rates.

CONCLUSIONS

Data from the WATER trial demonstrates that aquablation is comparable to TURP in effectively improving symptom scores and functional parameters related to BPE and bladder outlet obstruction. The evidence provided supports the safety of aquablation assessed by procedure-related adverse events.

The Role of Aquablation for the Surgical Treatment of LUTS/BPH

PURPOSE OF REVIEW

To explore the potential applicability of a novel, heat-free, and robotically controlled ablative therapy for surgical management of benign prostatic enlargement.

RECENT FINDINGS

With the emergence of new technology to provide personalized care and overcome the complications associated with options such as TURP, holmium laser enucleation of the prostate, GreenLight laser, or simple prostatectomy, Aquablation has been studied across a variety of prostate volumes. The functional outcome of Aquablation seems to be uncompromised by prostate volume. The sexual profile seems superior to TURP and the risk of retrograde ejaculation is lower. The robotic system provides a reproducible ablation, independent of prostate volume, without requiring extensive training for performing the procedure. The mean ablation time in the prostate as large as 150 ml does not exceed 9.1 min, and the blood transfusion rates do not seem to be higher than open prostatectomy.

Aquablation of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

BACKGROUND

New, minimally invasive surgeries have emerged as alternatives to transurethral resection of the prostate (TURP) for the management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Aquablation is a novel, minimally invasive, water-based therapy, combining image guidance and robotics for the removal of prostatic tissue.

OBJECTIVES

To assess the effects of Aquablation for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia.

SEARCH METHODS

We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 11 February 2019, with no restrictions on the language or status of publication.

SELECTION CRITERIA

We included parallel-group randomised controlled trials (RCTs) and cluster-RCTs, as well as non-randomised observational prospective studies with concurrent comparison groups in which participants with BPH who underwent Aquablation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion at each stage, and undertook data extraction and 'Risk of bias' and GRADE assessments of the certainty of the evidence. We considered review outcomes measured up to and including 12 months after randomisation as short-term and beyond 12 months as long-term.

MAIN RESULTS

We included one RCT with 184 participants comparing Aquablation to TURP. The mean age and International Prostate Symptom Score were 65.9 years and 22.6, respectively. The mean prostate volume was 53.2 mL. We only found short-term data for all outcomes based on a single randomised trial.Primary outcomesUp to 12 months, Aquablation likely results in a similar improvement in urologic symptom scores to TURP (mean difference (MD) -0.06, 95% confidence interval (CI) -2.51 to 2.39; participants = 174; moderate-certainty evidence). We downgraded the evidence certainty by one level due to study limitations. Aquablation may also result in similar quality of life when compared to TURP (MD 0.27, 95% CI -0.24 to 0.78; participants = 174, low-certainty evidence). We downgraded the evidence certainty by two levels due to study limitations and imprecision. Aquablation may result in little to no difference in major adverse events (risk ratio (RR) 0.84, 95% CI 0.31 to 2.26; participants = 181, very low-certainty evidence) but we are very uncertain of this finding. This would correspond to 15 fewer major adverse events per 1000 participants (95% CI 64 fewer to 116 more). We downgraded the evidence certainty by one level for study limitations and two levels for imprecision.Secondary outcomesUp to 12 months, Aquablation may result in little to no difference in retreatments (RR 1.68, 95% CI 0.18 to 15.83; participants = 181, very low-certainty evidence) but we are very uncertain of this finding. This would correspond to 10 more retreatments per 1000 participants (95% CI 13 fewer to 228 more). We downgraded the evidence certainty by one level due to study limitations and two levels for imprecision.Aquablation may result in little to no difference in erectile function as measured by International Index of Erectile Function questionnaire Erectile Function domain compared to TURP (MD 2.31, 95% CI -0.63 to 5.25; participants = 64, very low-certainty evidence), and may cause slightly less ejaculatory dysfunction than TURP, as measured by Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MD 2.57, 95% CI 0.60 to 4.53; participants = 121, very low-certainty evidence). However, we are very uncertain of both findings. We downgraded the evidence certainty by two levels due to study limitations and one level for imprecision for both outcomes.We did not find other prospective, comparative studies comparing Aquablation to TURP or other procedures such as laser ablation, enucleation, or other minimally invasive therapies.

AUTHORS' CONCLUSIONS

Based on short-term (up to 12 months) follow-up, the effect of Aquablation on urological symptoms is probably similar to that of TURP (moderate-certainty evidence). The effect on quality of life may also be similar (low-certainty evidence). We are very uncertain whether patients undergoing Aquablation are at higher or lower risk for major adverse events (very low-certainty evidence). We are very uncertain whether Aquablation may result in little to no difference in erectile function but offer a small improvement in preservation of ejaculatory function (both very low-certainty evidence). These conclusions are based on a single study of men with a prostate volume up to 80 mL in size. Longer-term data and comparisons with other modalities appear critical to a more thorough assessment of the role of Aquablation for the treatment of LUTS in men with BPH.