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Aquablation is a new technique used to treat BPH through the removal of benign prostate tissue. It has comparable functional outcomes compared to transurethral resection. Associated with this minimally invasive procedure, however, is postoperative blood loss, particularly in patients with larger prostates.
In a study presented at the 2021 American Urological Association Annual Meeting, Andrew Higgins, MD, and co-authors implemented electrocautery protocols to mitigate blood loss among patients who undergo Aquablation.1 Higgins is a urology resident at Einstein Healthcare Network, Philadelphia, Pennsylvania.
At our institution, we started doing Aquablation of the prostate, which uses an intense waterjet that's controlled by a robot to ablate prostate tissue in an effort to improve the outflow tract for treatment of BPH. They've compared this to the gold standard for BPH treatment, which is still transurethral resection of the prostate, or TURP. We've been performing this at our institution since about 2019. This study looks at our first 47 patients. We're trying to see how they [patients] are doing in the immediate post-op period, looking at what their postoperative blood loss is and ways to mitigate that postoperative blood loss. In our first 33 patients, we did a completely athermal technique, where we would do the Aquablation with the wand, ablate the tissue, and put in a catheter. We would then use only external traction for tamponade and use that in combination with continuous bladder irrigation to control the hematuria post-op.
There was then a shift in our institutional technique, with additional data coming out from other centers using Aquablation. We started doing electrocautery immediately after the initial aqua jet ablation, and we used electrocautery to spot fulgurate the bladder neck, which we found was the area of the bladder and prostate that was most likely to bleed after the procedure. We wanted to see whether it had really been having much of a difference in our initial experience.
From our standpoint, in short, bigger prostates bleed more. It's really not the most groundbreaking result. You would expect more tissues, more vascular, more likely to bleed, but this definitively proved that for us. From that, we started taking a different approach for those larger prostates. Our data in this initial cohort, where in the second group we started doing electrocautery of those patients, showed there was roughly 71% of them, 10 out of 14, that had prostates that were larger than 80 g, which was much larger than in our initial cohort of 33 patients [where only 7 or 21W% had glands >80 g) Those men tended to bleed more and needed catheters longer and some needed catheter replacement because of those larger prostates. Dr Dean Elterman just had a recent study published back in April, which showed that even though these prostates bleed more, you're able to control that bleeding more effectively by using this spot cautery system.2 We hope to replicate those results in our future work.
For our institution, we're continuing to do Aquablation and we look at our outcomes in the immediate post-operative period, looking at just blood loss, and whether or not we should send patients home with or without the catheter and whether or not that will play any role in decreasing ER admissions or patient tolerance of post-operative pain or earlier catheter removal. That's what we're working on right now. More long-term goals are looking at what the improvements are in urinary symptoms postoperatively and in quality of life. One of the big things, which is a very big selling point for Aquablation, is that it's one of the few outlet procedures for BPH that can preserve antegrade ejaculation after treatment. So, that's something that we really try and counsel patients on. With any outlet procedure, there is risk of dry ejaculations, anejaculations, or retrograde ejaculations. For some men, it's very important to make sure that they have an antegrade ejaculation [postoperatively] and this is a treatment modality that we're able to offer them.
At Einstein, we offer GreenLight, TURP, Aquablation, simple prostatectomies, Rezum, and UroLift. For our patients, we use any of those methods but we ask our patients what is their goal? You want to make them pee better, but are they willing to sacrifice antegrade ejaculation? How healthy are they for surgery? To select our treatment options, and whether we're trying to steer our patients for Aquablation, we generally pick men who have a medium to larger sized prostate gland, especially those men who are very interested in antegrade ejaculation. We really do steer them towards Aquablation because that's the only one we can really offer them and allow them to still have that [antegrade ejaculation] afterwards.
It's still a very early data set. There are only 47 people in this cohort, and it's still very much growing as we go forward. What we have changed is that we're still modifying how we're approaching these larger prostates. We're still going to keep on going and look at whether the spot cautery of the bladder neck really does help with decreasing hematuria postoperatively. In our data set, our study didn't show any difference in transfusion rates. Again, we think that’s largely just due to the way our data is structured in that the men in the cautery group had larger prostates which are more likely to bleed, and we just feel that there's a little bit of confounding data from that. As our dataset grows, we hope to be able to elucidate whether or not the cautery does or does not help. Other studies have shown that it does have benefit. From our standpoint, we're just going to continue doing the electrocautery going forward. We've also started looking at readmission rates or presentations to the emergency department. It seems like men with larger prostates tend to have more irritative symptoms after catheter removal, so we're now sending these men home with catheters for a few days to let any of the inflammatory response or edema of the prostate after the procedure go down and let them have a better chance of voiding afterwards.
What we are recommending is that if you're interested in pursuing Aquablation, go out and see how others do it. We recommend doing spot cautery [after the Aquablation]. You do the Aquablation procedure itself and once the scope is set up, that process only takes 5 to 10 minutes for the robot to go through and remove all the prostate tissue in the desired cut path that you've programmed into it. Then, you go in with the resectoscope and for about 10 or 15 minutes, you remove some of the fluffy tissue from the ablated zone. This tissue is very denuded, devascularized, and devitalized. It dies off slowly. By us going in with the resectoscope, we're able to get that tissue clear enough so we can actually find the base of the prostate that's still the raw, cut surface. That’s where we'll do that spot cautery, and we really focus on the bladder neck, which is what really tends to bleed. We really recommend going in and trying to get control of that bleeding. That will help you with your hematuria postoperatively. And if you have a choice between monopolar or bipolar…we seem to have some benefit by doing this with monopolar electrocautery. They tend to be a little bit drier afterwards.
This study is very much a preliminary study. We hope at AUA 2022 to present some more data on a larger cohort and with some more outcomes there. Urologists should consider Aquablation. I think it's good treatment, and if you have someone who's very concerned about antegrade ejaculation, it's a great treatment modality for them.
1. Higgins A, Ghiraldi E, Braun A, Sterious S. Prostate Aquablation: 2 years of perioperative outcomes. Paper presented at 2021 American Urological Association Annual Meeting; September 10-13, 2021; virtual. Abstract MP09-02
2. Elterman DS, Foller S, Ubrig B, et al. Focal bladder neck cautery associated with low rate of post-Aquablation bleeding. Can J Urol 2021;28(2)10610-10613