madman
Super Moderator
Purpose: Aquablation is a new technology that relies on real-time ultrasound guidance to ablate prostatic tissues using high-velocity pressurized water. We hereby present our data and experience in this technique by exploring the perioperative surgical and functional outcomes.
Materials and Methods: This is a prospectively filled study including consecutive patients who underwent aquablation at our Middle Eastern tertiary care center. Patient demographics, voiding parameters, and prostate disease-specific variables were collected. We reported on the surgical and functional outcomes as well as the 3-month adverse events. We also explored the trend in hemoglobin drop and hemostasis method by dividing the consecutive cases into four temporal periods.
Results: Fifty-nine patients underwent aquablation between March 2018 and March 2020. Meantime from transrectal ultrasound to Foley insertion was 48.5±2.5 minutes. Cautery was performed in 35 patients (59.3%) and a catheter-tensioning device was mounted in 50 patients (84.7%). On average, the hemoglobin dropped by -1.7±0.2 ng/dL (p<0.0001). The average length of catheterization and hospital stays were 2.1±0.3 days and 2.2±0.1 days, respectively. Only three patients (5.1%) were re-hospitalized. At three months, the average drop in serum prostate-specific antigen was -36.6±6.0% (p<0.0001), and functional outcomes considerably improved. We also recorded 14 adverse events in 13 patients (an overall rate of 22.0%), with grade 1 and grade 2 complications comprising 71.4% of all adverse events.
Conclusions: Our study results confirm the safety and efficacy of the aquablation procedure in the adoption phase.
INTRODUCTION
Benign prostatic obstruction (BPO) affects a fourth of men in their lifetime and begets a considerable economic burden to the healthcare system [1,2]. If refractory to medical treatment, surgical intervention is offered based on prostate size. Although traditionally performed by transurethral resection of the prostate (TURP) or open adenectomy, these procedures are lengthy and morbid for larger prostates (>80 mL) [3]. Instead, various energy sources are used to endoscopically enucleate medium to large prostatic adenomas [4]. In 2015, aquablation, a semi-autonomous robotic technique, was introduced to the armamentum of BPO surgery. This technology relies on real-time ultrasound feedback to athermally ablate tissue using high-precision and high-velocity pressurized water [4,5].
Multi-center prospective studies demonstrated the efficacy and safety of this procedure [6,7]. In the Waterjet Ablation Therapy for Endoscopic Resection (WATER I) of prostate tissue trial, the authors showed that aquablation has comparable functional outcomes to TURP, but has the superior ability in preserving ejaculation by sparing the verumontanum [6]. Desai et al.’s [7] WATER II trial also verified the applicability of aquablation to larger prostates (80–150 mL) without extending the procedure time. Since waterjet ablation is heat-free, bleeding is a foreseen adverse event. Hence, hemostasis is achieved using either spot electrocautery at the bladder neck, a catheter-tensioning device (CTD), or by standard tape traction secured to the patient’s leg [8]. However, a large study by Elterman et al. [8] showed that robust traction by CTD is associated with elevated transfusion rates. On the other hand, the use of selective cautery mitigated the hemoglobin drop but did not affect the transfusion rate.
Through our contribution to the first post-marketing multi-center study that validated the results in real-world patients, our institution became a pioneer of aquablation in the Middle East [3]. Thus, our early exposure allows us to share our experience and comment on the evolution of this technique. Therefore, we sought to present our cumulative data in aquablation, explore the perioperative outcomes, and highlight how our progress in the technique impacted the hemoglobin drop in the function of the prostate size.
CONCLUSIONS
Aquablation is a novel robotic procedure allowing a standardized treatment of BPO with limited adverse events. Our results echo the findings of other studies and confirm the safety and efficacy of the procedure. Evolution of the technique and experience with the use of selective cautery at the bladder neck, gentle traction, and appropriate postoperative pain control resulted in fewer complications.
Materials and Methods: This is a prospectively filled study including consecutive patients who underwent aquablation at our Middle Eastern tertiary care center. Patient demographics, voiding parameters, and prostate disease-specific variables were collected. We reported on the surgical and functional outcomes as well as the 3-month adverse events. We also explored the trend in hemoglobin drop and hemostasis method by dividing the consecutive cases into four temporal periods.
Results: Fifty-nine patients underwent aquablation between March 2018 and March 2020. Meantime from transrectal ultrasound to Foley insertion was 48.5±2.5 minutes. Cautery was performed in 35 patients (59.3%) and a catheter-tensioning device was mounted in 50 patients (84.7%). On average, the hemoglobin dropped by -1.7±0.2 ng/dL (p<0.0001). The average length of catheterization and hospital stays were 2.1±0.3 days and 2.2±0.1 days, respectively. Only three patients (5.1%) were re-hospitalized. At three months, the average drop in serum prostate-specific antigen was -36.6±6.0% (p<0.0001), and functional outcomes considerably improved. We also recorded 14 adverse events in 13 patients (an overall rate of 22.0%), with grade 1 and grade 2 complications comprising 71.4% of all adverse events.
Conclusions: Our study results confirm the safety and efficacy of the aquablation procedure in the adoption phase.
INTRODUCTION
Benign prostatic obstruction (BPO) affects a fourth of men in their lifetime and begets a considerable economic burden to the healthcare system [1,2]. If refractory to medical treatment, surgical intervention is offered based on prostate size. Although traditionally performed by transurethral resection of the prostate (TURP) or open adenectomy, these procedures are lengthy and morbid for larger prostates (>80 mL) [3]. Instead, various energy sources are used to endoscopically enucleate medium to large prostatic adenomas [4]. In 2015, aquablation, a semi-autonomous robotic technique, was introduced to the armamentum of BPO surgery. This technology relies on real-time ultrasound feedback to athermally ablate tissue using high-precision and high-velocity pressurized water [4,5].
Multi-center prospective studies demonstrated the efficacy and safety of this procedure [6,7]. In the Waterjet Ablation Therapy for Endoscopic Resection (WATER I) of prostate tissue trial, the authors showed that aquablation has comparable functional outcomes to TURP, but has the superior ability in preserving ejaculation by sparing the verumontanum [6]. Desai et al.’s [7] WATER II trial also verified the applicability of aquablation to larger prostates (80–150 mL) without extending the procedure time. Since waterjet ablation is heat-free, bleeding is a foreseen adverse event. Hence, hemostasis is achieved using either spot electrocautery at the bladder neck, a catheter-tensioning device (CTD), or by standard tape traction secured to the patient’s leg [8]. However, a large study by Elterman et al. [8] showed that robust traction by CTD is associated with elevated transfusion rates. On the other hand, the use of selective cautery mitigated the hemoglobin drop but did not affect the transfusion rate.
Through our contribution to the first post-marketing multi-center study that validated the results in real-world patients, our institution became a pioneer of aquablation in the Middle East [3]. Thus, our early exposure allows us to share our experience and comment on the evolution of this technique. Therefore, we sought to present our cumulative data in aquablation, explore the perioperative outcomes, and highlight how our progress in the technique impacted the hemoglobin drop in the function of the prostate size.
CONCLUSIONS
Aquablation is a novel robotic procedure allowing a standardized treatment of BPO with limited adverse events. Our results echo the findings of other studies and confirm the safety and efficacy of the procedure. Evolution of the technique and experience with the use of selective cautery at the bladder neck, gentle traction, and appropriate postoperative pain control resulted in fewer complications.
