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Dr. Friel and Dr. Sterling on patient selection for Aquablation for BPH


"Some of it actually is self-selecting because people are hearing about it more and come in asking about it first," says Brian Friel, MD.

In this video, Brian Friel, MD, and Matthew E. Sterling, MD, discuss patient selection for the Aquablation procedure for the treatment of benign prostatic hyperplasia. Friel and Sterling are urologists with MidLantic Urology.


What is patient selection like for Aquablation?

Friel: Some of it actually is self-selecting because people are hearing about it more and come in asking about it first. I do the same work-up in everyone. Everyone gets a cystoscopy to rule out other causes of low urinary symptoms and also so that you have a good understanding of what their anatomy looks like. With different people, there are different considerations. The other important thing, obviously, is prostate size. This varies very much practitioner to practitioner; we've been doing more somewhere between 50-g and 100-g prostates thus far. I know some people go much higher with their volume. We haven't done that yet. But those are the 2 main things, at least from my work-up standpoint, that I want to know: what their urethra looks like, what their bladder looks like, what their prostate looks like, what their prostate size is. And then obviously, what their symptoms are, to make sure that correlates with a need for it. Now, as far as counseling patients, that part is sometimes difficult, because they'll ask what's the difference, from a voiding standpoint, between a TURP and Aquablation, and there's not a lot. And so a lot of my conversation focuses on a couple of things. Some people like that it's a newer technology with image guidance, like we talked about. A lot of people focus on the ejaculatory function, which studies show 8% to 10% have retrograde ejaculation, much lower than a TURP. Like I said, I haven't proved that yet in my own data. And then the other consideration is bleeding, because there tends to be a little bit more blood in the urine after the procedure. If it's someone that's older, that's on blood thinners, things of that nature, those patients I may gear toward something like a TURP that has more cautery involved. We have all the options and try to make it a shared decision and not just me telling them, "This is right" or "that's right" and help guide them.

Sterling: Mine is the exact same. I do the same work-up for everyone. I do a scope, I do an ultrasound. I usually do urodynamics on everyone I'm going to operate on—not always, but I'd say more than 80% to 90% of the time. I do UroLift, I do Rezum, I do TURP, and I do Aquablation. If they fit within the criteria for any of them, I have a sheet that I go through with them. I talk about all their options. I talk about the risks and benefits of each. I think Dr. Friel hit it on the head; for larger prostates more than 50 g, Aquablation studies have shown it to be better than TURP. And certainly it is going to be better than some of the minimally invasive procedures, but everyone's different. Some patients will say, "I understand my urination symptoms might not be better, but I want a quicker recovery. And I want maybe a little bit lower risk." And so Rezum or UroLift might be a better option for those patients. I have other patients that say "I'd rather have something that's going to give me the best chance to void more normally." In larger prostates, definitely, I think, Aquablation is better. A lot of men want to maintain their sexual health, and that's not just erections; that includes ejaculation. When I talk about that, that's a big thing that I've noticed patients really want to maintain. The image guidance is big for patients too, that you're being more exact with things. TURP gets a really bad rap for some reason. Honestly, a lot of patients come in and say, "I absolutely don't want a TURP, but I'm okay with Aquablation." I try to tell them, "The outcomes are pretty similar," but I'm sure if you go on Reddit, Google, and forums, probably everyone that's had leakage or problems with a TURP [talks about it]. Now, TURPs are definitely more variable; every surgeon is different. Whereas I think Aquablation, you're going to find over time, it's going to end up more uniform, because you're using image guidance, you're using a robot to resect in a certain way. In that sense, again, from the learning curve, and from the uniformity, I think it's probably going to be better for the population of urologists. There are urologists that do really good TURPs, where Aquablation will be just the same, and there are some urologists do pretty bad TURPs, and then everyone gets a bad rap about a TURP, and then they come in and they already don't want that. Dr. Friel and I are not really pushy people. We kind of let the patient guide us where they want to go. The vast majority of patients that are having these surgeries are elective for just symptom bother. And so I let them guide me regarding what risks they're willing to take. Now, some patients, it's not purely just for symptoms and there are medical reasons; those are different stories. I'll push them a little bit more than they should have something done. But ultimately, they get to decide.

Friel: I totally agree. I try to be pretty transparent with people about recovery because I have had a lot of patients similar to Dr. Sterling that come in and say "I never want a TURP because my father had a TURP and it seemed like the worst thing of all time." Now, they also had a TURP 30 years ago without a camera and monopolar that they tried to do as fast as they can. And that is a different TURP. I don't paint it all with rainbows. I give them an honest opinion on both sides because I want to make sure they're as comfortable with the decision as I am. Ultimately, that's going to give you your best patient results.

This transcription was edited for clarity.

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