What is the appropriate management for a 52‑year‑old man on postoperative day 3 after Aquablation for benign prostatic hyperplasia with a post‑void residual of 250 mL, given rising pre‑operative post‑void residuals of 70 mL, 150 mL, and 220 mL?

Management of Elevated Post-Void Residual on Postoperative Day 3 After Aquablation

Immediate Management Decision

Continue catheter drainage for an additional 24–48 hours and repeat PVR measurement before making any definitive treatment decisions, as a single PVR measurement on postoperative day 3 is unreliable and does not mandate invasive intervention. 1

Understanding the Clinical Context

Your patient's PVR of 250 mL falls within the clinically significant range (200–300 mL), but several critical factors argue against aggressive intervention at this early postoperative timepoint:

• Measurement variability is substantial: Treatment decisions should never rely on a single PVR measurement due to marked intra-individual test-retest variability; confirmation with repeated measurements is required. 1, 2

• Early postoperative context matters: This is postoperative day 3 after tissue ablation—transient bladder dysfunction from surgical trauma, edema, and inflammation is expected and typically resolves within the first week. 3, 4

• Pre-operative trajectory was concerning but not prohibitive: The rising pre-operative PVR values (70→150→220 mL) suggest progressive bladder dysfunction, but none exceeded the 250 mL threshold where antimuscarinic agents are contraindicated. 1

Recommended Management Algorithm

Days 3–5 (Current Phase)

• Maintain catheter drainage for an additional 24–48 hours to allow resolution of acute postoperative edema and inflammation. 4

• Avoid premature catheter removal: Early studies of Aquablation showed mean hospital stays of 1.6 days, but bleeding complications occurred in 8% of patients prior to discharge and 6% after discharge, suggesting that early catheter removal may be problematic. 4

Day 5–7 (Trial of Voiding)

• Remove catheter and perform repeat PVR measurement at least 2–3 times over 24 hours using transabdominal ultrasound to establish reliability. 1, 2

• If PVR remains 100–200 mL: Initiate intermittent catheterization every 4–6 hours to prevent bladder filling beyond 500 mL and stimulate normal physiological filling and emptying. 1

• If PVR >200 mL on repeated measurements: Implement scheduled intermittent catheterization every 4–6 hours and evaluate for underlying causes including persistent obstruction from residual tissue, blood clots, or detrusor underactivity. 1

Weeks 2–6 (Monitoring Phase)

• Re-evaluate at 4–6 weeks after initiating any treatment to assess response using repeat PVR and uroflowmetry. 1, 2

• Regular voiding diaries and symptom assessment should guide ongoing management, with monitoring for urinary tract infection recurrence. 1

Critical Pitfalls to Avoid

• Do not place an indwelling catheter long-term: No specific PVR volume alone mandates invasive therapy or placement of an indwelling catheter; intermittent catheterization is the gold standard when catheterization is needed. 1

• Do not assume obstruction: Elevated PVR cannot differentiate between bladder outlet obstruction and detrusor underactivity without urodynamic studies—pressure-flow studies are the only method to distinguish these conditions. 1, 2

• Do not start antimuscarinic medications: These agents should be avoided in patients with PVR >250–300 mL, as they can exacerbate urinary retention. 1

• Do not ignore the pre-operative trajectory: The rising pre-operative PVR values (70→150→220 mL) suggest underlying bladder dysfunction that may have been exacerbated by surgery, warranting closer long-term follow-up. 1, 2

Aquablation-Specific Considerations

• Bleeding risk: Initial Aquablation studies showed hemorrhage rates approaching 8.3%, though systematic cautery loop hemostasis has reduced this to 1.4%. 3 Ensure hemostasis was adequate at the time of surgery.

• Expected outcomes: In the WATER II trial of large prostates (80–150 mL), mean PVR decreased from 131 mL at baseline to 47 mL at 6 months, with maximum urinary flow rate increasing from 8.7 to 18.8 mL/s. 4 Your patient's current PVR of 250 mL is higher than expected but may improve with time.

• Catheter duration: The mean length of hospital stay after Aquablation was 1.6 days in the WATER II trial, but 19% of patients experienced adverse events, with bleeding complications being most common. 4 Extended catheterization in your patient is reasonable given the failed voiding trial.

Long-Term Prognosis

• Retreatment rates: Recent real-world data shows 12.9% of patients required surgical retreatment after Aquablation, with higher rates in prostates ≥150 mL. 5

• Medication continuation: At 6 months post-Aquablation, 22.9% of patients continued alpha-blockers and 12.9% continued androgen receptor inhibitors, suggesting that some patients require ongoing medical management. 5

• If PVR remains elevated at 6 weeks: Consider urodynamic studies to differentiate persistent obstruction from detrusor underactivity, as this will guide further management (repeat surgical intervention vs. intermittent catheterization vs. medical therapy). 1, 2