Is aqua ablation a suitable treatment option for Benign Prostatic Hyperplasia (BPH)?

Aquablation for Benign Prostatic Hyperplasia (BPH)

Aquablation is an effective treatment option for BPH with comparable symptom improvement to TURP but with lower rates of sexual side effects, particularly for men concerned about preserving ejaculatory function. 1

What is Aquablation?

Aquablation is a surgical procedure that:

• Uses a robotic handpiece, console, and conformal planning unit (CPU) to perform prostate resection 1
• Requires general anesthesia (not classified as minimally invasive surgical therapy) 1
• Employs high-velocity water jets for targeted removal of prostatic tissue 2
• Utilizes real-time ultrasound imaging with robotic assistance for precision 2
• Achieves hemostasis via electrocautery or catheter balloon traction after resection 1

Efficacy and Outcomes

Symptom Improvement

• Provides sustained improvements in International Prostate Symptom Score (IPSS) comparable to TURP through 12 months (RR 0.9 [95%CI 0.7 to 1.1]) 1, 3
• Demonstrates durable outcomes with 50% improvement in IPSS from baseline at 36 months 1
• Shows significant improvement in quality of life scores (49% improvement from baseline at 3 years) 1

Urinary Flow Rates

• Produces similar maximum flow rate (Qmax) improvements compared to TURP at 12 months (10.3 vs. 10.6 mL/s) 1
• Maintains >50% improvement in Qmax from 3 to 24 months and 39% improvement at 36 months 1

Safety Profile

Complications

• Results in fewer Clavien-Dindo grade 2 complications compared to TURP at 3 months (26% vs. 42%, p=0.015) 1
• Shows similar rates of bladder spasms, bleeding, dysuria, pain, and urethral damage as TURP 1
• Has comparable blood transfusion and reoperation rates to TURP (very low quality evidence) 1

Sexual Function Preservation

• Demonstrates significantly lower rates of retrograde ejaculation compared to TURP (6% vs. 23%, p=0.002) 1
• May better preserve sexual function with fewer patients reporting worsening sexual function compared to TURP (33% vs. 56%, p=0.03) 1, 3

Patient Selection Considerations

Prostate Characteristics

• Effective for various prostate sizes, including large prostates up to 150cc 4, 5
• Can be used for prostates with intravesical median lobes 6
• Results in less prostate volume reduction compared to TURP (31% vs. 44%, p=0.007) 1

Previous BPH Procedures

• Can be safely used in patients who have failed previous BPH procedures 4
• Shows similar perioperative and 90-day postoperative outcomes in retreatment cases compared to treatment-naïve patients 4
• May require fewer Aquabeam passes in retreatment cases but potentially higher rates of additional procedures at follow-up 4

Limitations and Considerations

• Long-term data beyond 3 years is currently limited 1, 3
• Evidence quality is moderate for symptom improvement but low to very low for other outcomes 3
• Retreatment rates and long-term efficacy need further evaluation with larger studies 3
• The American Urological Association gives Aquablation a Conditional Recommendation with Evidence Level Grade C 1

Clinical Decision Making

When considering Aquablation for BPH, prioritize:

1. Patients concerned about preserving sexual function, particularly ejaculatory function 1, 3
2. Men with prostate volumes ranging from small to large (up to 150cc) 4, 5
3. Cases with intravesical median lobes that might limit other minimally invasive options 6
4. Patients who have failed previous BPH procedures 4

Aquablation represents a valuable addition to the surgical armamentarium for BPH, offering comparable symptom relief to TURP with potentially fewer sexual side effects, though long-term data and higher quality evidence are still needed for definitive conclusions 1, 3.