3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 3 Benign prostatic hyperplasia: an update on minimally invasive therapy including Aquablation modalities, only a handful have gained popularity and stood the test of time. 1 We aim to provide a review and update on the current landscape of minimally invasive therapy for BPH, with specific focus on prostatic artery embolization, Aquablation, water vapor thermal therapy (Rezum), and prostatic urethral lift (Urolift). Prostatic artery embolization (PAE) PAE is aminimally invasive interventional radiological technique that can be performed under local anesthesia usually with intravenous (IV) conscious sedation. Vascular access through the femoral or radial arteries and small embolization particles are injected directly into the prostatic arteries bilaterally in order to devascularize adenomatous tissue. There is a slight advantage since it does not require any transurethral manipulation. However, the procedure requires experienced radiologists to perform as it is technically challenging with a large variation in prostatic arterial anatomy seen across patients. In the UK Register of Prostate Embolization (UK-ROPE) study, Ray et al investigated the efficacy and safety of PAE for LUTS secondary to BPH in an indirect comparative study between PAE and TURP. 2 The prospective multicenter matched cohort study recruited 305 total patients (216 PAE, 89 TURP) across 17 UK urological/interventional radiology centers. While the results showed that PAE may provide clinically and statistically significant improvement in symptoms and quality of life (QoL), TURP demonstrated superior improvements in median International Prostate Symptom Score (IPSS) (-15.0 versus -10.0 [PAE]) and QoL (-4.0 versus -3.0 [PAE]) scores with lower overall reoperation rates (5.6% versus 19.9% [PAE]) at 12 months post-procedure. To further assess the role of PAE in BPH treatment, Zumstein et al performed a systematic review and meta-analysis with results suggesting that PAE is not as effective as established surgical therapies (TURP, open prostatectomy). However, PAE may result in fewer adverse events and side effects including patient-reported erectile function (International Index of Erectile Function 5 [IIEF5]). 3 Although prostatic embolization may be limited or inferior compared to gold standard surgical therapies for BPH, PAE has still been shown to provide symptomatic benefit in patients with significant LUTS. Pisco et al performed a randomized, single blind, sham-controlled superiority clinical trial showing this treatment effect. 4 Patients in the PAE arm demonstrated significantly greater improvement in IPSS (p < 0.0001) and QoL scores (p < 0.0001) at 6 months post-procedure compared to the sham arm. Nevertheless, despite Food and Drug Administration (FDA) approval in 2017, PAE is considered by current AUA guidelines to be purely experimental with recommendations against its use outside of clinical and experimental trials. 5 Therefore, large-scale randomized controlled trials with longer follow up periods are necessary before PAE is considered as an alternative therapy for BPH-LUTS management to TURP. Aquablation Aquablation is performed using the AQUABEAM Robotic System (PROCEPT BioRobotics Inc., Redwood City, CA, USA) and was approved by the FDAin 2017. The technique involves an ultrasound-guided, robot- assisted waterjet that can precisely ablate prostatic tissue. Faber et al first described the procedure in 2015 6 with multiple updated techniques published by others. 7,8 Current AUA guidelines recommend Aquablation in symptomatic BPH patients with prostate sizes 30-80 grams. 5 Surgery requires a robotic handpiece, console, and conformal planningunit (CPU) and is performed under general or spinal anesthesia. The patient is positioned in dorsal lithotomy and the bi-planar transrectal ultrasound (TRUS) probe is positioned. TRUS is utilized before treatment to map out specific prostatic tissue to be ablated. This is performed using the mapping software, allowing for changes in depth up to 25 millimeters (mm) and angle of resection up to 225 degrees. Using the software, the desired area of ablation is outlined on a screen, with special care to avoid ablation in the area of the verumontanum. TRUS is then also used to monitor tissue resection in real-time during treatment as a targeted high velocity saline stream from the transurethrally placed robotic handpiece ablates tissue in a “windshield wiper” motion, with the computer system automatically adjusting the flow rate in each direction to alter the depth of penetration. Importantly, this procedure does not generate thermal energy, with safety mechanisms built in place to ensure that only the outlined tissue is ablated with the external sphincter protected. After completion of ablation, further hemostasismaybe needed by electrocautery via a standard cystoscope/resectoscope or light traction with a Foley catheter balloon. Post-procedure, a three-way catheter is required for continuous bladder irrigation. Aquablation is a newer technology, lacking robust data and published literature. To our knowledge, the WATER trial represents the first randomized controlled trial studying Aquablation. This was a double-blind,