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

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.

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.

Artificial intelligence: A new tool in surgeon's hand

Artificial intelligence (AI) is the future of surgery. Technological advancements are taking place at an incredible pace, largely due to AI or AI-backed systems. It is likely that there will be a massive explosion or "Cambrian explosion" of AI in our everyday life, largely aided by increased funding and resources spent on research and development. AI has also significantly revolutionized the medical field. The concept of machine learning and deep learning in AI is the crux of its success. In surgical practice, AI has numerous applications in the diagnosis of disease, preoperative planning, intraoperative assistance, surgical training and assessment, and robotics. The potential automation of surgery is also a possibility in the next few decades. However, at present, augmentation rather than automation should be the priority. In spite of the allure of AI, it comes with its own price. A robot lacks the "sixth sense" or intuition that is crucial in the practice of surgery and medicine. Empathy and human touch are also inimitable characteristics that cannot be replaced by an AI system. Other limitations include the financial burden and the feasibility of using such technology on a wide scale. Ethical and legal dilemmas such as those involving privacy laws are other issues that should be taken under consideration. Despite all these limitations, with the way technology is progressing, it is inevitable that AI and automation will completely change the way we practice surgery in the near future. Thus, this narrative review article aims to highlight the various applications and pitfalls of AI in the field of surgery.

Emerging minimally invasive transurethral treatments for benign prostatic hyperplasia: a systematic review with meta-analysis of functional outcomes and description of complications

INTRODUCTION

Several minimally invasive surgical procedures have been proposed as alternative therapies for benign prostatic hyperplasia (BPH). The present systematic review aimed to describe the functional outcomes and complications of emerging minimally invasive transurethral treatments for BPH.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE and Cochrane Library databases was conducted. No chronological restriction was applied. Retrospective and prospective primary studies were included. A meta-analysis of IPSS, IPSS-QoL, Qmax, and PVR was performed. Data on adverse events were presented narratively.

EVIDENCE SYNTHESIS

A total of 18 studies were included. Thirteen papers were eligible for the meta-analysis. iTIND, Rezūm, and Aquablation were associated with a significant improvement in IPSS (p<0.001), IPSS-QoL (p<0.001), and Qmax (p<0.001) compared to baseline. A significant reduction of PVR from baseline was found with Rezūm (p<0.001) and Aquablation (p<0.001) but not iTIND (p=0.22). A significant difference in IPSS, IPSS-QoL, and Qmax was shown in favor of Aquablation compared to Rezūm and iTIND (p<0.001). Rezūm and iTIND were mainly associated with mild to moderate adverse effects. Hematuria or bleeding was reported in all studies regarding Aquablation (0.8%-26%), the need for transfusion or intervention for bleeding varied between 1.8% and 9%.

CONCLUSIONS

Aquablation, Rezūm, and iTIND significantly improve urinary functional outcomes compared to baseline; however, Aquablation would seem to lead to better functional results compared to the other procedures. Rezūm and iTIND appear to have an excellent safety profile, while Aquablation would seem to expose patients to a nonnegligible risk of bleeding.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction

PURPOSE

To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).

METHODS

A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.

RESULTS

Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.

CONCLUSIONS

Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

Single center retrospective analysis of fifty-two prostate cancer patients with customized MR-guided transurethral ultrasound ablation (TULSA)

OBJECTIVES

MR-guided transurethral ultrasound ablation (TULSA) has primarily been investigated for whole-gland prostate ablation, even though the technology is also well-suited for partial gland treatment. The objectives were to perform a clinical service evaluation of partial to whole-gland TULSA for patients with localized prostate cancer (CaP). TULSA was also evaluated as a combined therapy for a subset of patients presenting with both cancer and concurrent benign prostate hyperplasia (BPH).

SUBJECTS AND METHODS

This retrospective, consecutive clinical service evaluation included men with histopathologically-confirmed CaP who underwent TULSA either as primary or salvage treatment. The planned ablation was dependent on the individual tumor characteristics, concurrent BPH and patient preferences. The Clavien-Dindo classification was used to record complications. Surgeon-assessed functional outcomes were reported. Early treatment success was defined by negative multiparametric MRI (mpMRI) and lack of prostate specific antigen (PSA) recurrence.

RESULTS

Fifty-two consecutive patients (47 treatment-naïve and 5 salvage) were included, with median follow-up of sixteen months and a max of thirty-six months. Baseline median (IQR) age and PSA were 67 years (63-76) and 8.0 ng/ml (5.2-13), respectively. Two Grade IIIa adverse events were observed, with no bowel-related complications. For urinary continence outcomes, 1 patient worsened to 1 pad per day. All patients who were previously potent maintained erectile potency. Of the patient subgroup also seeking treatment for BPH, 83% reported symptom improvement. Median (IQR) PSA nadir after primary treatment was 1.1 ng/ml (0.5-2.1). Early treatment success was 88%. Nine patients underwent a single repeat TULSA.

CONCLUSION

Customized prostate ablation with TULSA offers flexible ablation according to patients' disease characteristics and treatment expectations, providing favorable safety and promising early MRI and PSA results. TULSA is a feasible combination therapy for patients with both cancer and concurrent BPH.

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.

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.

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.

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.

[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.