Is Aquablation a recommended surgical option for patients with Benign Prostatic Hyperplasia (BPH) and total urinary restriction?

Aquablation for BPH with Total Urinary Retention

Surgery is recommended for patients with refractory urinary retention who have failed at least one attempt at catheter removal, with Aquablation being a conditionally recommended surgical option for BPH treatment. 1, 2

Efficacy for Urinary Retention

• The American Urological Association (AUA) recommends Aquablation for BPH with a Conditional Recommendation and Evidence Level Grade C, citing its effectiveness in providing sustained improvements in International Prostate Symptom Score (IPSS) comparable to TURP through 12 months 2
• For patients with urinary retention specifically, the AUA guideline states that surgery remains the treatment of choice for refractory retention, assuming the patient is an acceptable surgical risk 1
• Aquablation demonstrates durable outcomes with 50% improvement in IPSS from baseline at 36 months and significant improvement in quality of life scores 2

Advantages of Aquablation for BPH with Retention

• Aquablation produces similar maximum flow rate (Qmax) improvements compared to TURP at 12 months (10.3 vs. 10.6 mL/s) and maintains >50% improvement in Qmax from 3 to 24 months 2
• It results in fewer Clavien-Dindo grade 2 complications compared to TURP at 3 months (26% vs. 42%, p=0.015) 2
• Significantly lower rates of retrograde ejaculation compared to TURP (6% vs. 23%, p=0.002), making it particularly valuable for sexually active patients 2
• Recent evidence shows it is effective and safe even for patients who have had previous BPH procedures, with similar perioperative and 90-day postoperative outcomes compared to treatment-naïve patients 3

Safety Considerations

• Blood transfusion is a notable risk with Aquablation (31% reported in the MAUDE database compared to 16% for PUL and 1% for TWVT) 4
• Severe or life-threatening adverse events were reported more frequently with Aquablation (78%) compared to other minimally invasive procedures like PUL (52%) and TWVT (15%) 4
• Rare but serious complications include rectal perforation (4 cases reported in the MAUDE database) 4
• Initial issues with hemostasis have been addressed with the use of gentle bladder-neck cautery after the procedure 5

Limitations and Considerations

• Long-term data beyond 3 years is currently limited according to the AUA 2
• Evidence quality is moderate for symptom improvement but low to very low for other outcomes 2
• Retreatment rates and long-term efficacy need further evaluation with larger studies 2
• The procedure is typically performed in high-volume centers, though results can potentially be replicated elsewhere 5

Algorithm for Patient Selection

1. Confirm diagnosis of BPH with total urinary retention
2. Attempt at least one catheter removal trial (possibly with alpha-blocker therapy) 1
3. If retention is refractory, evaluate surgical candidacy
4. For surgical candidates, consider Aquablation particularly if:
   • Patient has concerns about sexual function preservation 2, 5
   • Patient has a prostate volume between 30-150cc 5, 6
   • Patient has failed previous BPH procedures 3
5. Discuss with patient the balance of benefits (comparable efficacy to TURP, sexual function preservation) versus risks (potential for bleeding requiring transfusion)

Common Pitfalls to Avoid

• Failing to recognize the risk of bleeding complications with Aquablation, which may require blood transfusion in some cases 4
• Not considering prostate size in treatment planning, though recent evidence suggests Aquablation is feasible for large prostates (80-150 mL) 5, 6
• Overlooking the need for specialized equipment and training, as Aquablation requires robotic technology and real-time ultrasound guidance 6