Aquablation for BPH: Harnessing the Power of Water

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Some men with benign prostatic hyperplasia (BPH) develop symptoms that are troubling enough to warrant treatment. In 2017, the U.S. Food and Drug Administration (FDA) approved the AquaBeam Robotic System to perform the procedure, known as aquablation (aqua is Latin for “water,” and ablation means “to remove” or “reduce in volume”).

How it’s performed. After the patient receives general or spinal anesthesia, a handpiece is inserted into the prostatic urethra and secured in place. Using real-time transrectal ultrasound guidance, the surgeon “maps” the area to be treated, sparing the bladder neck and urinary sphincter. The surgeon then triggers the robotically controlled handpiece to release a high-pressure stream of sterile saline to destroy the excess prostate tissue. The stream moves in a controlled manner from the bladder to the end of the prostate (verumontanum). The entire procedure takes less than an hour; the aquablation portion lasts about 10 minutes. An overnight hospital stay is typically required.

Recent findings. Researchers recruited 181 men (age 45–80) with intolerable BPH symptoms and randomly assigned them to undergo treatment with transurethral resection of the prostate (TURP)—the “gold standard” procedure for treating lower urinary tract symptoms—or aquablation. More than 90 percent were sexually active.

Two-year results, published in 2019 in Advances in Therapy, showed that both groups experienced similar improvement of symptoms. International Prostate Symptom Scores (IPSS), which rate the severity of BPH symptoms from 0 (none) to 35 (worst possible), improved by an average of 14.7 points in the aquablation group and 14.9 points in the TURP group. Urine flow also improved significantly in both groups. Of the sexually active men, 10 percent of those who had aquablation experienced retrograde ejaculation, compared with 36 percent of those who had TURP. No new cases of ED were reported in either group. However, more men in the aquablation than in the TURP group required retreatment; 4.3 percent and 1.5 percent, respectively.

Caveats. Researchers don’t yet know how the men have fared beyond two-year mark. So, long-term evidence of effectiveness and need for retreatment is limited. Nevertheless, the most recent American Urological Association (AUA) guidelines say the treatment can be offered to men with prostates weighing less than 80 grams. Short-term results from studies of men with larger prostates have shown similar improvements in symptom relief. Long-term data are needed to confirm those findings. Finally, because general anesthesia is used, some surgeons don’t consider the treatment to be minimally invasive.