What is aquablation therapy for benign prostatic hyperplasia (BPH)?

Aquablation Therapy for Benign Prostatic Hyperplasia (BPH)

Aquablation is a robotic-assisted surgical procedure that uses high-velocity water jets to remove prostate tissue in patients with BPH, providing similar symptom improvement to TURP with fewer sexual side effects. 1

What is Aquablation?

Aquablation is a surgical treatment for BPH that utilizes:

• A robotic handpiece, console, and conformal planning unit (CPU)
• High-velocity water jets for non-thermal ablation of obstructing prostatic tissue
• Real-time transrectal ultrasound imaging for precise targeting
• General anesthesia (not considered a minimally invasive surgical therapy)
• Hemostasis achieved via electrocautery or catheter balloon traction after resection 1

The procedure involves:

1. Treatment planning using ultrasound imaging to map the prostate anatomy
2. Robotic delivery of high-velocity water jets to ablate the obstructing tissue
3. Cystoscopic washout and hemostasis after ablation 2

Efficacy and Outcomes

Aquablation has demonstrated:

• Similar symptom improvement to TURP through 12 months (RR 0.9 [95% CI 0.7 to 1.1]) 1
• Sustained improvements in International Prostate Symptom Score (IPSS), quality of life, and maximum flow rate (Qmax) through 36 months 1
• At 36 months, mean IPSS improvement of 11.0 points (50% from baseline) and quality of life improvement of 49% from baseline 1
• Similar maximum flow rate improvements compared to TURP at 12 months (10.3 vs. 10.6 mL/s) 1
• Effective treatment for large prostates (80-150 mL) and those with intravesical median lobes 3, 4

Safety Profile and Advantages

Compared to TURP, Aquablation shows:

• Fewer Clavien-Dindo grade 2 complications at 3 months (26% vs. 42%, p=0.015) 1
• Significantly lower rates of retrograde ejaculation (6% vs. 23%, p=0.002) 1
• Less sexual dysfunction (33% vs. 56% reporting worsening sexual function at 6 months, p=0.03) 1
• Similar rates of other complications including bladder spasms, bleeding, dysuria, pain, and urethral damage 1
• Less reduction in prostate volume at 3 months (31% vs. 44%, p=0.007) 1

Clinical Applications and Patient Selection

Aquablation is particularly beneficial for:

• Patients concerned about preserving sexual function 1, 2
• Men with larger prostates (30-150 mL) 4
• Patients with intravesical median lobes 3

Limitations and Considerations

• Requires general anesthesia unlike some minimally invasive options 1
• Long-term durability beyond 3 years is still being established 5
• Higher risk of complications in larger prostates, though still clinically acceptable 4
• Received a Conditional Recommendation with Evidence Level Grade C from the American Urological Association 1

Comparison to Other BPH Treatments

The American Urological Association (AUA) guidelines position Aquablation as:

• One of several surgical options for BPH treatment 1
• Having similar efficacy to TURP but with better sexual function preservation 1
• Not classified as a minimally invasive surgical therapy (MIST) due to the requirement for general anesthesia 1

Aquablation represents an important advancement in BPH treatment, offering a balance between effective symptom relief and preservation of sexual function, with particular benefits for men with larger prostates or those concerned about sexual side effects.