Aquablation - image-guided robot-assisted waterjet ablation of the prostate: initial clinical experience

Benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a histopathologic definition associated with enlargement of the prostate gland that causes obstruction of the lower urinary tract and manifests clinically with characteristic symptoms that are what bring patients for consultation. Urinary tract symptoms are common, especially in an increasingly aging population. Diagnosis and the decision on when and how to treat depend on the patient's quality of life and objective clinical parameters. An individualized, risk-based approach is necessary to guide conservative, pharmacologic, or surgical treatment.

Bladder Outlet Obstruction Relief and Symptom Improvement Following Medical and Surgical Therapies for Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: A Systematic Review

BACKGROUND AND OBJECTIVE

Symptomatic benefit and urodynamic obstruction relief represent relevant outcomes of therapies for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). We summarized evidence from studies concurrently assessing variations in terms of symptoms severity and invasive urodynamic measures of obstruction following medical and surgical therapies for LUTS/BPH.

METHODS

We performed a systematic review of PubMed, Scopus, and Web of Science in June 2023.

KEY FINDINGS AND LIMITATIONS

We identified 29 publications: 14 (872 patients) and 15 (851 patients) studies addressing medical and surgical therapies, respectively. The mean percentage total International Prostate Symptom Score (IPSS) improvements ranged from -2.5% to 56.3% and from 35.1% to 82.1% following medical and surgical therapies, respectively. The corresponding mean percentage Bladder Outlet Obstruction Index (BOOI) improvements ranged from 7.8% to 53.5% and from 22.4% to 138.6%, respectively. Holmium laser enucleation of the prostate (HoLEP) provided IPSS improvements in the higher range and the greatest BOOI reduction.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Globally, based on available evidence, more pronounced symptomatic benefits are observed following treatments providing greater deobstructive effect. In detail, patients undergoing surgery exhibit greater IPSS and BOOI improvements than those receiving medical therapy.

Systematic review and network meta-analysis of re-intervention rates of new surgical interventions for benign prostatic hyperplasia

OBJECTIVE

To assess the re-intervention rates of new surgical benign prostatic hyperplasia (BPH) interventions, as the clinical durability of new surgical interventions for BPH is not widely known.

METHODS

A critical review of new surgical BPH therapies namely 'UroLift®', 'Aquablation', 'Rezum', 'prostatic artery embolisation (PAE)' and 'temporary implantable nitinol device (iTIND)' was performed on PubMed, the Cochrane Library, and Embase databases between May 2010 and December 2022 according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. All relevant articles were reviewed, and the risk of bias was evaluated using the Cochrane risk assessment tool and Newcastle-Ottawa Scale.

RESULTS

Of the 32 studies included, there were 10 randomised controlled trials and 22 prospective observational cohorts. A total of 2400 participants were studied with a median patient age of 66 years, a median prostate volume of 51.9 mL, and a median International Prostate Symptom Score of 22. The lowest re-intervention rate at 12 months was for Aquablation at 0.01%, followed by Rezum at 0.02%, iTIND at 0.03%, and PAE at 0.05%. Network meta-analysis (NMA) showed that the best-ranked treatment at 12 months was transurethral resection of the prostate (TURP), followed by Aquablation, iTIND, Rezum, and UroLift. Re-intervention rates with these new BPH interventions are comparable, although some interventions reported better outcomes than TURP in the shorter term.

CONCLUSIONS

While this systematic review and NMA showed that the re-intervention rate with these new surgical BPH interventions appears to be comparable to TURP in the short term, further studies are required to directly compare these various BPH procedures.

Aquablation at 4-years: Real World Data From the Largest Single-center Study With Associated Outcomes Follow-up

OBJECTIVE

To report real-world experience of 4-year safety and efficacy outcomes of Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia (BPH).

METHODS

This is a prospective single-center, observational study evaluating the outcomes of robotic-assisted Aquablation therapy for moderate-to-severe BPH between December 2019 and December 2023. Patient-level data included age, prostate volume, IPSS score, peak urinary flow rate (Qmax), post-void residual (PVR) were evaluated at 3 M, 6 M, and Years 1-4. Primary outcomes included change in IPSS score, change in Qmax, change in PVR, preservation of antegrade ejaculation, and complications.

RESULTS

In this cohort of 330 men, mean prostatic volume was 110.3 mL (range 38-330 mL) at baseline. International Prostate Symptom Score (IPSS) improved from a baseline of 23.8 (SD 8.4) to 6.9 (SD 2.9) at 4 years. Mean peak urinary flow rate (Qmax) also demonstrated improvement and increased from 6.4 mL/sec (SD 4.2) to 17.4 mL/sec (SD 5.5) at 4 years. At 1 year, mean prostate volume reduction was 45.5 mL (-41.3%). Postoperative antegrade ejaculation was preserved in 249/250 men (99.6)% of men. Complications included urinary tract infection within first month after procedure in 37 (11.2%) and bleeding requiring blood transfusion in 11 (3.3%). Thirteen patients (3.9%) required a second procedure including 2 for post-operative bleeding, 1 for a bladder neck disruption and 10 (3.0%) for transurethral resection of residual anterior tissue.

CONCLUSION

We demonstrate Aquablation to not only be safe but also providing durable outcomes at 4 years for men with BPH.

Evaluating the Impact of Benign Prostatic Hyperplasia Surgical Treatments on Sexual Health

Benign prostatic hyperplasia (BPH), a prevalent condition in older men, is often managed through various surgical interventions. This narrative review aims to explore the impact of these surgical treatments on sexual function, a critical aspect of patient quality of life often overlooked in BPH management. The methodology encompassed a thorough review of contemporary surgical techniques for BPH, including prostate resection, enucleation, vaporization, and minimally invasive therapies such as UroLift, Rezum, and Aquablation. Additionally, the focus was on patient-centered outcomes, with a special emphasis on sexual health following surgery. Findings reveal that, while surgical interventions effectively alleviate BPH symptoms, they often have significant repercussions in sexual function, including erectile and ejaculatory dysfunction. However, emerging techniques demonstrate potential in preserving sexual function, underscoring the need for patient-centric treatment approaches. The study highlights the complex interplay between BPH surgery and sexual health, with minimally invasive treatments showing promise in balancing symptom relief and sexual function preservation. In conclusion, the study advocates for an integrated, interdisciplinary approach to BPH treatment, emphasizing the importance of considering sexual health in therapeutic decision-making. This narrative review suggests a paradigm shift towards minimally invasive techniques could optimize patient outcomes, marrying symptom relief with quality-of-life considerations. The need for further research in this domain is evident, particularly in understanding long-term sexual health outcomes following different surgical interventions for BPH.

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.

Procedural Intervention for Benign Prostatic Hyperplasia in Men ≥ Age 70 Years - A Review of Published Literature

Objective

We set out to review studies reporting on the use of surgical intervention to treat Benign Prostatic Hyperplasia in elderly men ≥70 years of age.

Methods

A systematic literature search was conducted using Scopus, PubMed-MEDLINE, Cochrane, and Wiley Online Library databases including studies published between January 2012 through December 2022. This 10-year interval was chosen given the recent plethora of new modalities that have entered the BPH armamentarium, many of which have been marketed as appropriate for older and high-risk patients. The following database search words were used either individually or in conjunction: "BPH", "elderly", "surgical", "ablation", "resection", "embolization", and "aging".

Results

We identified 28 studies for inclusion in this review. The pros and cons of these modalities are presented, specifically as applicable to an older and higher risk population.

Conclusion

There are a wide variety of surgical procedures available for surgically treating BPH in elderly men with varying states of health. Each of these comes with different risks and benefits, supporting that individualized approaches are important. Long-term data and further studies comparing modalities, specifically as regards the elderly and frail, would enhance our approaches to BPH treatment in this patient population.

Novel minimally invasive treatments for lower urinary tract symptoms: a systematic review and network meta-analysis

PURPOSE

To review and compare the effectivity of novel minimally invasive treatments (MITs) to transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) in men.

METHODS

Medline, Embase, and Cochrane databases were searched from January 2010 to December 2022 for randomized controlled trials (RCTs) evaluating MITs, compared to TURP or sham, in men with LUTS. Studies were assessed by risk of bias tool, and evidence by GRADE. Functional outcomes by means of uroflowmetry and IPSS were the primary outcomes, safety and sexual function were secondary outcomes. As part of this review, a network meta-analysis (NMA) was conducted. MITs were ranked based on functional outcome improvement probability.

RESULTS

In total, 10 RCTs were included, evaluating aquablation, prostatic urethral lift, prostatic artery embolization (PAE), convective water vapor thermal treatment or temporary implantable nitinol device. All MITs showed a better safety profile compared to TURP. Functional outcome improvement following aquablation were comparable to TURP. In the NMA, aquablation was ranked highest, PAE followed with the second highest probability to improve functional outcomes. Other novel MITs resulted in worse functional outcomes compared to TURP. Level of evidence was low to very low.

CONCLUSIONS

Five MITs for treatment of LUTS were identified. Aquablation is likely to result in functional outcomes most comparable to TURP. Second in ranking was PAE, a technique that does not require general or spinal anesthesia. MITs have a better safety profile compared to TURP. However, due to high study heterogeneity, results should be interpreted with caution.

Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function

CONTEXT

Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO).

OBJECTIVE

To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907).

EVIDENCE SYNTHESIS

A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] -0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI -0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD -1.37 pts; 95% CI -3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD -0.80 pts; 95% CI -2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006).

CONCLUSIONS

Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk.

PATIENT SUMMARY

Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

Functional and surgical outcomes of Aquablation in elderly men

PURPOSE

As benign prostatic hyperplasia (BPH) is an age-related process, growing interest in surgical management for elderly men has emerged. Recently, Aquablation was approved for treatment of BPH associated lower urinary tract symptoms (LUTS) and utilizes robotic ultrasound guided surgeon-controlled waterjet ablation. We assessed the differences in functional and surgical outcomes between elderly and young men undergoing Aquablation for BPH/LUTS.

MATERIALS AND METHODS

We retrospectively assessed prospectively collected data from the WATER I (NCT02505919) and WATER II (NCT03123250) clinical trials reporting safety and efficacy of Aquablation in the treatment of LUTS/BPH in men 45-80 years with a prostate between 30 and 80 cc, and 80 cc and 150 cc, respectively. Men ≥ 65 years were defined as elderly and men < 65 years as young.

RESULTS

Of 217 patients included, 83 (38.2%) were young and 134 (61.8%) were elderly. Mean age (SD) was 59.3 (± 3.4) years and 71.2 (± 4.2) years for young and elderly men, respectively. At 3 years of follow-up compared to baseline, elderly men showed similar reductions in total IPSS (7.68 points vs 7.12 points, p > 0.05) and similar increases in Qmax (20.6 mL/s vs 19.3 mL/s, p > 0.05) compared to young men. The ejaculatory dysfunction rate was similar for both cohorts (12.0% vs 9.7%, p > 0.05). Elderly men experienced similar annual retreatment rates compared to young men (1.5% vs 0.8% p > 0.05).

CONCLUSIONS

Elderly men undergoing Aquablation have similar functional and surgical outcomes as young men. Elderly patient BPH surgical counseling should, therefore, consider Aquablation as a treatment option for LUTS/BPH.

Technique, outcome and changes in prostate dimensions in patients with urinary retention managed by aquablation

Purpose

This study aimed to investigate the functional and urodynamic outcome of Aquablation in patients with acute urinary retention (AUR) on catheters.

Methods

Men aged 50–70 who failed medical treatment of BPO with AUR failing to wean off urethral catheter were recruited to undergo Aquablation. Individuals were assessed pre-operatively and at 3 and 6 months after surgery. The primary outcome was defined by the success rate of weaning off catheter. Secondary outcomes were measured by a change in prostate size, symptom scores and urodynamic parameters.

Results

Twenty patients underwent Aquablation between June 2019 and September 2020. Mean duration of the urethral catheter in-situ was 5.9 ± 4.9 weeks and mean prostate size of the cohort pre-operatively was 60.8 ± 15.8 cc. A second pass Aqaublation treatment was performed in 14 patients. Five patients failed to wean off the catheter on the first attempt after surgery, requiring another attempt 1 week later which were all successful. At 3 months after the operation, a significant reduction in prostate volume was observed (60.8 ± 15.8 cc vs 24.9 ± 10.3 cc, p < 0.001). No change in international index of erectile function (IIEF) was found (baseline: 16.1 ± 5.8; 3-month: 14.9 ± 6.4; p = 0.953). Mean bladder outlet obstruction index was 14.2 ± 23.0 at 6 months upon urodynamic assessment with 75% of patients had a resolution of detrusor overactivity. Reduction in prostate length was found to be more significant than a reduction in width and height after Aquablation (R = 0.693, p = 0.039).

Conclusion

From the early data of a single centre, Aquablation was shown to provide a consistent improvement in symptoms, uroflowmetry and urodynamic parameters in patient with a urethral catheter. Results from our study suggest that improvement from Aquablation is reproducible in patients with AUR.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03244-y.

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.

Surgical treatment options for benign prostatic obstruction: beyond prostate volume

PURPOSE OF REVIEW

Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization.

RECENT FINDINGS

A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezūm, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezūm, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP.

SUMMARY

BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

New Technologies for Treatment of Benign Prostatic Hyperplasia

BPH is a common disease in aging men which impacts quality of life. With advancing age expectation coupled with the rising demand for BPH therapy, new technologies have been developed that target rapid recovery and symptom relief, low complication rates, and the ability to perform the procedure in an outpatient setting with local anesthesia. MIST technologies have fostered BPH medical care with ejaculation preservation. Techniques and outcomes for BPH technologies including Aquablation, Rezūm, UroLift, iTind, Optilume BPH, XFLO, Zenflow, and Butterfly are reviewed and evaluated. Given the novelty of these technologies, long-term data are required to assess safety and efficacy.

Do Minimally Invasive Benign Prostatic Hyperplasia Treatments Preserve Sexual Function? A Contemporary Review of the Literature

PURPOSE OF REVIEW

The aim of this study is to compare the sexual function outcomes related to minimally invasive surgical therapies (MISTs) (UroLift^®, Rezum™, Aquablation^®, prostate artery embolization, and iTind^®) for the treatment of benign prostatic hyperplasia (BPH).

RECENT FINDINGS

Clinical trials and retrospective data evaluating MISTs for BPH have demonstrated improved or stable sexual function outcomes when compared to sham control or transurethral resection of the prostate. Outcomes were assessed at baseline and following treatments using patient-reported outcome measures. Rezum and Aquablation demonstrated preservation of overall ejaculatory function and erectile function at 36-month follow-up. Similar outcomes occurred with UroLift after a 60-month follow-up. Erectile function was preserved following prostate artery embolization and iTIND up to 12 months. MIST for the management of BPH has been demonstrated to be effective in improving urinary function and appears to minimize potential collateral damage on sexual function following treatment.

Aquablation therapy in large prostates (80–150 cc) for lower urinary tract symptoms due to benign prostatic hyperplasia: WATER II 3‐year trial results

Objective

The objective of this study is to determine if Aquablation therapy can maintain its effectiveness in treating men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with large‐volume (80–150 cc) prostates at 3 years.

Subjects and Methods

One hundred one men with moderate‐to‐severe BPH symptoms and prostate volumes between 80 and 150 cc were enrolled in a prospective, nonrandomized, multicenter, international clinical trial in late 2017. Baseline, procedural, and follow‐up parameters were recorded at baseline and scheduled postoperative visits. IPSS, Qmax, and treatment failure are reported at 3 years.

Results

The mean prostate volume was 107 cc (range 80–150). Mean IPSS improved from 23.2 at baseline to 6.5 at 3 years (16.3‐point improvement, p < 0.0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 3 years (improvement of 3.4 points, p < 0.0001). Maximum urinary flow increased from 8.7 to 18.5 cc/s. At 3 year follow‐up, 6% of treated patients needed BPH medication and an additional 3% required surgical retreatment for LUTS.

Conclusions

Three‐year follow‐up demonstrates a sustained symptom reduction response along with low irreversible complications to Aquablation in men with LUTS due to BPH and prostates of 80–150 cc. Current treatment options available for men with prostates of this size have similar efficacy outcomes but are burdened with high rates of irreversible complications. There are now numerous clinical studies with Aquablation used in various prostates sizes, and it should be offered as an option to men with LUTS due to BPH.

A Standardized Method for Estimating the Carbon Footprint of Disposable Minimally Invasive Surgical Devices: Application in Transurethral Prostate Surgery

Objective

To propose a standardized methodology for estimating the embodied carbon footprint (CF) of disposable minimally-invasive surgical devices (MISDs) and their application in new benign prostatic hyperplasia (BPH) MISDs.

Summary of Background Data

The estimation of the CO2e emissions of disposable surgical devices is central to empowering the healthcare supply chain.

Methods

The proposed methodology relied on a partial product lifecycle assessment and was restricted to a specific part of scope 3, which comprised the manufacturing of surgical device- and non-device-associated products (NDAPs), including packaging and user manual. The process-sum inventory method was used, which involves collecting data on all the component processes underpinning disposable MISDs. The seven latest disposable MISDs used worldwide for transurethral prostatic surgery were dismantled, and each piece was categorized, sorted into the appropriate raw material group, and weighed. The CF was estimated according to the following formula: activity data (weight of raw material) × emission factors of the corresponding raw material (kg CO2e/kg).

Results

The total weights of disposable packaging and user manuals ranged from 0.062 to 1.013 kg. Plastic was the most common and least emissive raw material (2.38 kg CO2e/kg) identified. The estimated embodied CF of MISDs ranged from 0.07 to 3.3 kg CO2e, of which 9% to 86% was attributed to NDAPs.

Conclusions

This study described a simple and independent calculation method for estimating the embodied CF of MISDs. Using this method, our results showed a wide discrepancy in the estimated CO2 emissions of the most recent disposable MISDs for transurethral BPH surgery. Thus, the lack of CF information should be of major concern in the development of future MISDs.

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.

Aquablation versus holmium laser enucleation of the prostate in the treatment of benign prostatic hyperplasia in medium-to-large-sized prostates (ATHLETE): protocol of a prospective randomised trial

INTRODUCTION

A novel method for the surgical treatment of benign prostatic hyperplasia (BPH) called Aquablation has become commercially available. Previous studies have been able to show similar functional results when compared with transurethral resection of the prostate and a high efficacy has been demonstrated when this approach is applied to patients with a prostate size of 80-150 cm³.Holmium laser enucleation of the prostate (HoLEP) is a well-established procedure in the surgical treatment of BPH in prostate glands larger than 30 mL and a first-line therapy in glands over 80 mL. To date, no data are available whether Aquablation is non-inferior compared with HoLEP in the treatment of patients with medium-to-large-sized prostates regarding safety and efficacy.

METHODS AND ANALYSIS

This is a prospective, randomised, open-label, non-inferiority clinical trial conducted at a Swiss centre of tertiary care. The primary outcome is assessment of non-inferiority of Aquablation compared with HoLEP in reducing lower urinary tract symptoms due to benign prostatic obstruction measured by the International Prostate Symptom Score (IPSS). Randomisation will be performed using secuTrial, stratifying on age (<70 years, 70+ years) and prostate volume (<100 mL, 100+ mL). Both interventions are performed in an inpatient setting and regular follow-up controls starting 8 weeks after intervention and continuing up to 5 years will be performed. The primary outcome (change in IPSS from baseline to 6 months) will be tested for non-inferiority with a one-sided t-test. Secondary outcomes, such as efficacy parameters, several patient-reported outcome measures, and periprocedural and safety parameters will be described by calculating means or relative frequencies for each treatment group and testing differences with two-sided standard superiority tests.

ETHICS AND DISSEMINATION

The study was approved by the local ethics committee (EKOS 2020-02353). Results of the primary endpoint and each of the secondary endpoints will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04560907).

Feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation for the treatment of benign prostatic hyperplasia: a single institutional experience

PURPOSE

To evaluate the feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation (TPLA) as a new minimally invasive surgical therapy (MIST) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Under local anesthesia and conscious sedation up to two laser fibers for each prostatic lobe were inserted under US-guidance by a percutaneous approach. TPLA was performed using a continuous wave diode laser (SoracteLite-EchoLaserX4) able to generate a light-induced thermal heating and subsequent coagulative necrosis of the prostatic tissue. Patients were evaluated at 3, 6, and 12 months after TPLA.

RESULTS

Twenty-two consecutive patients were prospectively enrolled (median age 61.9 years). All procedures were well tolerated and no procedural complications were recorded. Median catheterization time was 7 days, while the median hospitalization time was 1 day. Three out of twenty-two patients (13.6%) experienced acute urinary retention and two (9.1%) of them urinary tract infection requiring major antibiotic treatment. At 3, 6, and 12 months, median prostate volume significantly decreased by a - 21.3%, - 29%, and - 41%, respectively. At the same time point, median IPSS was 8 (- 63.6%), 5 (- 74%), and 6 (- 75%), while median QoL score was 1 in all the scheduled timepoints of follow-up. The median postoperative Qmax at 3, 6, and 12 months improved by + 57.8%, + 98%, and + 115.8%, respectively. Ejaculatory function was preserved in 21 out of 22 patients (95.5%).

CONCLUSIONS

TPLA of the prostate appears to be a promising MIST for BPH. Long-term results and comparative studies against standard treatments are warranted before implementations of this technique in the urologist's armamentarium.

Rectal perforation after aquablation of the prostate: lessons learned the hard way

INTRODUCTION

Transurethral resection of the prostate and open prostatectomy have been the standard of care for the surgical treatment of benign prostatic obstruction (BPO) over decades. New emerging techniques for the surgical management of BPO have been currently introduced, but might be associated with new, unusual complications.

METHODS

We herewith report on two patients with a rectal perforation after aquablation treatment of BPO.

RESULTS

In the first case, the diagnosis was made 2 days after the aquablation procedure due to unspecific postoperative symptoms. A complex combined open/endoscopic repair of the defect was carried out thereafter. As a consequence, a rectoscopy was routinely performed since then following each aquablation procedure. In the second case, intraoperative rectoscopy after uneventful aquablation revealed the rectal perforation. The perforation was clipped immediately with an over the scope-clip by colonoscopy.

CONCLUSIONS

These two cases of a rectal perforation after aquablation of the prostate demonstrate an unusual complication and its complex management. Diagnostic delay complicates its treatment. Therefore, immediate rectoscopy should be performed routinely after the aquablation procedure.

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.

Interventional therapy in benign conditions of the prostate

Interventional therapies (IT) are increasingly popular treatment options for benign prostatic hyperplasia (BPH). IT aim to reduce morbidity and side effects related to invasive surgical procedures. To date, IT are considered experimental, though they are evolving rapidly and starting to challenge established surgical strategies. With gradually increasing evidence for the benefits of IT in BPH, several techniques are moving out of the realm of research and into everyday clinical practice. As such, IT provides encouraging mid-term functional outcomes with improved health-related quality of life (QoL), particularly in terms of better preservation of ejaculation. The distinct role IT could play as a bridge between exhausted drug-based treatment options and surgery is yet to be defined. Further studies are required before IT can be recommended as alternatives to invasive therapies. Systematic trials are needed to identify subgroups of patients who can benefit particularly from IT in comparison to other treatments, to identify features of the prostate particularly suited to a specific IT, and to analyze the durability of success for each technique.

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.

Initial single centre experience of Aquablation of the prostate using the AquaBeam system with athermal haemostasis for the treatment of benign prostatic hyperplasia: 1-year outcomes

PURPOSE

Aquablation using the AquaBeam system combines real-time image guidance and robotics to enable precise and heat-free removal of prostatic tissue with a high velocity water jet. The aim of this study is to report the outcomes of Aquablation up to 1 year in a single centre within the UK employing an athermal approach to haemostasis.

METHODS

Fifty-five consecutive men underwent Aquablation between September 2017 and December 2018 (as part of OPEN WATER trial). Standard Aquablation was performed with the AquaBeam system (PROCEPT^® BioRobotics) with 2 passes of Aquablation followed by bladder washout with application of continuous bladder irrigation via a catheter on a continuous traction device. Patients were followed up at 3 and 12 months. The data were prospectively collected on patient demographics, uroflowmetry, prostate volume, International Prostate Symptom Score (IPSS), Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EjD) and International Index of Erectile Function (IIEF-15).

RESULTS

The mean age was 64.1 ± 7.9 years. Operating time was 26.9 ± 9.2 min. Mean prostate volume decreased from 58.2 ± 23.9 cc to 33.2 ± 12.9 cc (p < 0.0001). There were significant improvements at the 12 month follow-up in maximum urinary flow rate (9.9 ± 5.1 ml/s vs. 23.9 ± 11.6 ml/s), IPSS (21.7 ± 7.4 vs. 6.1 ± 4.2) and quality of life score (4.8 ± 1.1 vs. 1.4 ± 1.4) (p < 0.0001). There was no significant change in IIEF-15 and MSHQ-EjD scores. There were 8 (14.5%) Clavien grade 2 or higher complications.

CONCLUSION

Our single centre experience suggests Aquablation using an entirely athermal approach is a safe cavitating procedure resulting in significant LUTS improvement comparable to standard cavitating procedures with greater preservation of sexual function.

A state-of-art review on the preservation of sexual function among various minimally invasive surgical treatments for benign prostatic hyperplasia: Impact on erectile and ejaculatory domains

There is a strong association between benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and sexual dysfunction. While transurethral resection of the prostate (TURP) is considered the standard BPH treatment, it is however associated with a high rate of erectile and ejaculatory dysfunctions. Over the past decade, new and novel minimally invasive BPH therapies have been shown to improve various parameters of voiding domains while minimizing adverse sexual effects. These minimally invasive BPH therapies can be largely be divided into those with cavitating technology (Rezum, Histotripsy, Aquablation), intra-prostatic injections (Botulinum neurotoxin Type A, Fexapotide Triflutate, prostate specific antigen-activated protoxin PRX-302), and mechanical devices which include intraprostatic stents (Urospinal 2™, Memotherm™, Memokath™, and Allium triangular prostatic stent™) and intraprostatic devices (iTIND™, Urolift™), as well as prostatic artery embolization. Published literature on these technologies showed reasonable preservation of erectile function with limited data reported on ejaculatory domain. Further validation of the performance of these novel minimally invasive treatment options for LUTS due to BPH in well-designed and multi-centre studies are desired, to evaluate their role (or lack of such a role) in clinical practice and whether these BPH therapies can provide equivalent standard or better than TURP.

How can we Preserve Sexual Function after Ablative Surgery for Benign Prostatic Hyperplasia?

Our aim was to provide a narrative review regarding the prevalence, the associated pathophysiologic pathways and the potential management methods of sexual dysfunction related to ablative surgical techniques for Benign Prostatic Enlargement (BPE). Men suffering from BPE are at high risk of sexual dysfunction due to the disease itself, comorbidities, and pharmacological/surgical treatments. Transurethral resection of the prostate, as the gold standard treatment option for BPE, has historically been associated with relatively high rates of postoperative sexual dysfunction problems, mainly retrograde ejaculation but also erectile dysfunction. Ablative surgical techniques, including photoselective vaporization of the prostate (PVP), transurethral needle ablation (TUNA), Transurethral Microwave Therapy (TUMT), Convective Water Vapor Energy Ablation (Rezum®) and Aquablation®, have been proposed as treatment methods able to reduce treatment-related complications for BPE patients, including adverse effects on erectile and ejaculatory function, without compromising the efficacy rates for BPE. The neurovascular bundles can be damaged during TURP due to posterolateral capsular perforation. Ablative techniques and especially PVP theoretically seem to skip this hazard, as the distance created from the necrotic area to the capsule is generally larger compared to the distance induced after TURP. However, indirect thermal injury of erectile nerves, which could also be induced by the majority of available ablative techniques, could potentially lead to ED. Two special technical characteristics (physiological saline use for tissue ablation and real time penetration depth control) of Aquablation® could be proved beneficial with regard to the effect of the method on erectile function. In general, ablative techniques seem to have a minor impact on sexual function. However, low methodological quality characterizes most of the studies included in this review mainly due to the impossibility, in many cases, to perform blind randomization. Also, many studies did not have an erectile and ejaculatory function as primary outcomes limiting that way their statistical power to identify significant variations. Management of sexual dysfunction problems arising from ablative surgeries for BPE treatment could be divided into two levels. Firstly, intraoperatively the avoidance of manipulation of crucial structures regarding ejaculatory (bladder neck or ejaculatory ducts) and erectile function (neurovascular bundles) could possibly decrease the negative effect of these procedures on sexual function. Thus, in this direction, modifications of classic ablative techniques have been proposed resulting in encouraging outcomes regarding postoperative sexual function. Secondly, if EjD and/or ED are established, the already known treatment choices should be chosen in order for sexual function rehabilitation to be achieved. Thus, regarding ED: PDE5i daily or on-demand remains the gold standard first-line treatment choice followed by intracavernosal alprostadil injections in cases of failure, while penile prosthesis implantation must be kept as the final definitive solution when all the other methods have failed. Regarding ejaculation disorders (retrograde ejaculation or anejaculation): medical therapy with a-agonists (pseudoephedrine), sperm retrieval from the urine, bladder neck reconstruction, prostatic massage, electroejaculation, penile vibratory stimulation and surgical sperm retrieval are the available treatment options. Furthermore, high-quality studies are required to investigate the potential side effects of BPE surgery on sexual function and efficient treatment methods to manage them.

[An update on the most recent mini-invasive surgical and interventional techniques in the management of benign prostatic obstruction]

INTRODUCTION

New surgical techniques for the treatment of benign prostatic obstruction (BPO) have emerged in recent years. We sought to give an overview on each of these technologies.

MATERIAL

A comprehensive review of the literature between 2013 and 2020 was carried out by a panel of national experts already practicing these interventions. All the data were then discussed among all the co-authors in order to obtain a consensus with regard to the selected articles and their analysis. Finally, an inventory was drawn to provide an overview of these technological advances and their availability in France.

RESULTS

The treatment benign prostatic obstruction has diversified greatly over the past 5 years. 5 new technologies have emerged, allowing today a transurethral non-ablative treatment (UROLIFT®, ITIND®), a transurethral ablative treatment (REZUM®), a transurethral ablative treatment with robotic assistance (AQUABEAM®) or an endovascular management by embolization of the prostatic arteries. Only UROLIFT® is considered an established technology in the latest EAU-Guidelines. The other four are under evaluation and recommendations have only been issued for two of them, AQUABEAM® and the embolization of the prostatic arteries.

CONCLUSION

These new minimally invasive techniques aim to increase the therapeutic options for the management of BPO in order to offer a management more suited to the wishes of the patient. Some are positioned as an alternative to surgical or medical treatment, others between medical and surgical treatment. These technologies are not all at the same level of development, evaluation and level of proof, but have in common a limited distribution in France, in particular given their cost. Validated studies will allow them to position their subsequent use more precisely.

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.

An Update on Minimally Invasive Surgery for Benign Prostatic Hyperplasia: Techniques, Risks, and Efficacy

Benign prostatic hyperplasia (BPH), a common cause of lower urinary tract symptoms in the elderly male population, has conventionally treated by transurethral resection of the prostate (TURP). During recent years, newer minimally invasive therapies (MITs) have entered the playing field and challenged TURP with their convenience, lack of sexual side effects, and overall safety. The present paper provides an update on the more heavily studied and most recent MITs, analyzing their mechanism of action, tolerability, and efficacy in clinical practice. Particularly, robust clinical data have propelled UroLift and Rezuum to the forefront in the armamentarium of minimally invasive BPH treatment. Newer mechanical therapies such as the temporary implantable nitinol device, ClearRing, ZenFlow Spring, and Butterfly are appealing options as they forego cutting, ablation, heating, or removing prostatic tissue. It is obvious that there is wide variation in the degree of clinical readiness of each modality and only time and long-term, multicenter studies will decide which of these therapies are accepted by the patient and urologist.

Informative value of histological assessment of tissue acquired during aquablation of the prostate

PURPOSE

To determine the histological validity of the tissue acquired during aquablation of the prostate.

PATIENTS AND METHODS

Prostatic tissue of 12 patients that consecutively underwent aquablation for benign prostatic enlargement was systematically examined. Histological examination was performed by two experienced uropathologists using a digital slide scanner and slide viewer software (Pannoramic 250 and Case Viewer 2.3, 3D Histech, Hungary). The surface areas of the assessable glands were examined and set in relation to the total surface area of the material available for histology and to the patient's total prostate volume. Examinations were performed analogously in ten consecutive patients undergoing transurethral resection of the prostate (TURP) to facilitate interpretation of the results. Data were analyzed using descriptive statistics.

RESULTS

A median of 4.06% (range 1.43-7.5%) of the preoperative total prostate volume (median 64.5 ml (range 40-80 ml)) was obtained for histological examination by aquablation. Due to severe mechanical destruction and fragmentation, only a proportion of 0.43% (0.06-1.79%) of this tissue represented histologically assessable glands. Therefore, roughly 0.017% of the total prostatic volume was available for a reliable histological examination. In comparison, 32.5% (6.67-37.5%) of the total prostate volume was removed by TURP and 22.86% (7.45-40.57%) of this tissue represented informative prostatic glands, corresponding to 7.43% of the total prostate volume.

CONCLUSION

Histological significance of the tissue obtained by aquablation of the prostate is very limited. Costs and effort of the histological examination must, therefore, be weighed critically against the limited informative value.

[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.

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.

Modern best practice in the management of benign prostatic hyperplasia in the elderly

Benign prostatic hyperplasia (BPH), with its associated lower urinary tract symptoms (LUTS), can be a debilitating disease in the elderly male. Transurethral resection of the prostate (TURP) remains the gold standard; however, many patients will choose to avoid surgery if possible. Medical therapy is an effective alternative, however, new studies are showing that there may be more side effects than previously realized in the elderly male. Newer, novel minimally invasive techniques, including UroLift® and Rezūm™, are gaining favor as alternative office-based procedural techniques that do not require general anesthesia and may better preserve ejaculatory function. Though promising, at this point, these techniques are not approved for all patients. With a range of medical, procedural, and surgical options for treatment of BPH with LUTS, it is important to have a discussion with your patient regarding the short- and long-term risks and benefits, as well as alternatives, before deciding on a treatment plan for your patient with BPH.

A glimpse into the efficacy of alternative therapies in the management of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a common disease that can cause uncomfortable lower urinary tract symptoms. The occurrence of symptomatic BPH develops after the age of 40 years and increases gradually with age to reach more than 50% at the age of 60 years and severely disturbs the quality of life of the patients. Alpha-blockers and 5‑alpha reductase inhibitors are first-line agents used for the treatment of BPH. Due to the adverse effects of these conventional therapies, many patients turn to phytotherapy and other alternative therapies. This review covers alternative therapies, i.e., phytotherapy (cernilton, eviprostat, quercetin, saw palmetto and pumpkin seed) and physical therapy (acupuncture, aquablation, pulsed electromagnetic field, prostate urethral lift, radial extracorporeal shock wave therapy, thermobalancing therapy, and transurethral needle ablation) commonly used in the management of BPH.

First Multi-Center All-Comers Study for the Aquablation Procedure

Waterjet-based prostate resection (Aquablation procedure) is an increasingly recognized treatment for symptomatic benign prostatic hyperplasia (BPH). We confirmed the safety and effectiveness of the Aquablation procedure in the commercial setting in 178 men at five sites. The mean prostate volume was 59 cc. The procedure time averaged 24 min and total anesthesia duration was 50 min. The International Prostate Symptom Score (IPSS) decreased from 21.6 at the baseline to 6.5 at the 12-month follow-up, a 15.3-point improvement (p < 0.0001). The maximum urinary flow rate increased from 10 cc/s at the baseline to 20.8 cc/s at month 12 (increase of 11.8 cc, p < 0.0001). Ejaculatory function was relatively preserved. Prostate volume assessed with transrectal ultrasound decreased 36% by month three. Five patients (2.7%) underwent a transfusion in the first week after the procedure. Real-world evidence shows that Aquablation is safe and effective for the treatment of BPH.

Transperineal Laser Ablation Treatment for Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction: Protocol for a Prospective In Vivo Pilot Study

BACKGROUND

Standard surgical treatments for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) use a transurethral approach. Drawbacks are the need for general or spinal anesthesia and complications such as hematuria, strictures, and cloth retention. Therefore, a minimal invasive technique under local anesthesia is desired to improve patient safety. Recently, SoracteLite transperineal laser ablation (TPLA) has been introduced as a novel minimal invasive treatment for BPO. The system used is unique because 4 laser sources are independently available. This 1064-nm diode laser induces coagulative necrosis. Moreover, TPLA is unique because it has a transperineal approach and can be performed under local anesthesia in an outpatient setting.

OBJECTIVE

The primary objective of this study is to determine the safety and feasibility of TPLA treatment for men, who are fit for standard surgery, with LUTS due to BPO. The secondary objectives are to determine functional outcomes by flowmetry and patient-reported outcome measures (PROMs), side effects, and tissue changes observed on imaging.

METHODS

This study is a prospective, single center, interventional pilot study IDEAL framework stage 2a and will include 20 patients. Eligible patients are men ≥40 years of age, with a prostate volume of 30 to 120 cc, have urodynamically proven bladder outlet obstruction, and have a peak urinary flow of 5 to 15 mL per second. All patients will undergo TPLA of their prostate under local anesthesia by using the EchoLaser system. Depending on the prostate volume, 2 to 4 laser fibers will be placed bilaterally into the prostate. Patient follow-up consists of uroflowmetry, PROMs, and imaging by using contrast-enhanced ultrasound. Total follow-up is 12 months following treatment.

RESULTS

Presently, recruitment of patients is ongoing. Publication of first results is expected by early 2020.

CONCLUSIONS

TPLA offers the potential to be a novel minimal invasive technique for treatment of LUTS due to BPO in men fit for standard desobstruction. This study will evaluate the safety and feasibility of TPLA and report on functional outcomes and tissue changes observed on imaging following TPLA treatment.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15687.

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.

A review of surgery and new technology procedures for the management of benign prostatic obstruction

Level of evidence: Not applicable for this review article.

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.

Evolving Technologies for Tissue Cutting

This article reviews evolving and lesser known technologies for tissue cutting and their application in oral and maxillofacial surgery.