4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 reduce operative time, relative to other widely used endoscopic techniques such as TURP and holmium laser enucleation of the prostate (HoLEP). This technique also shows promise in preserving sexual function, both erectile and ejaculatory, similar to the effects seen with prostatic urethral lift (Urolift, Neotract/Teleflex, Pleasanton, CA, USA) and convective water vapor therapy (Rezum, Boston Scientific, Marlborough, MA, USA) procedures. This article updates a previous review, 5 examines the use of Aquablation and provides an update on the newer longer termdata that recently became available. Technique The technique for this procedure was first described by Farber et al in 2015 using the Aquabeam system has been further described by several others. 6-8 The AquaBeam Aquablation system has three main components: the conformal planning unit (CPU); robotic 24 Fr handpiece; and a console. The procedure can be performed under general anesthesia or spinal anesthesia. From here the patient is placed in the dorsal lithotomy position, and the biplanar transrectal ultrasound (TRUS) is mounted into position. Next, the handpiece is used to gain access to the bladder to allow visualization with a cystoscope. The handpiece is positionedwith the tip just inside the bladder before the scope is retracted to visualize the bladder neck, and placed proximal to the external sphincter. Once proper positioning is confirmed, the handpiece can be stabilized using an articulating attachment mounted to the bed. Once secured, the TRUS probe can be inserted until the center of the prostate is visualized. At this point, the surgeon can use the ultrasound probe to compress the prostate and improve visualization for the Aquabeam handpiece. Once the handpiece andTRUS probe are positioned, the software must be adjusted to confirm appropriate planning for the tissue ablation, which is performed using the mapping software. The software allows for changes in depth up to 25 millimeters, and the angle of resection up to 225 degrees. Complete ablation of the transition zone is performed by outlining the prostate with the Aquabeam software. A high velocity jet of physiologic saline is then initiated under the control of a foot pedal. The computer system automatically adjusts the flow rate in each direction to alter the depth of penetration and remove the tissue as outlined in the mapping stage. There are safety mechanisms in place to ensure only the outlined tissue is ablated, and the external sphincter remains protected. Once resection is complete, hemostasis can be completed either through electrocautery or balloon catheter tamponade, with expert opinion favoring balloon tamponade. 9 The balloon remains in place for 2 hours to ensure hemostasis. Post procedure, a 3-way catheter is inserted and bladder irrigation is commenced and patients can be discharged the following day after the catheter has been removed. Outcomes and safety of Aquablation While this procedure is relatively new, several authors have been able to publishmedium term followup data for their cohorts. Some of the earliest outcomes were reported by Gilling et al, who published their findings in a prospective, multicenter trial at three Australian centers which included 21 men. 10 All patients were between the ages of 50 and 80 years and had prostate volumes ranging from 30 to 102 mL. The results from this study showed an average procedural duration of 38 minutes and a mean resection time of 5 minutes, with an average hemoglobin drop of 0.8 gr/dL after the operation. Subjective and objective findings were also reported, with data from 1, 3, 6, and 12 months. Average international prostate symptom scores (IPSS) were significantly decreased down to an average of 6.8 frompretreatment values. Maximumflow rate (Qmax) increased to 18.3 mL/second at 12 months follow up. Post void residual (PVR) volume decreased down to an average of 31 mL, and quality of life subjective scores improved significantly as well. The authors obtained urodynamics studies after the operation for comparison to baseline and found that detrusor pressure at maximum flow was decreased by 40% on average. Prostate volume reduced by 39% on average as well. Finally, no adverse events were reported, there were no reports of incontinence, and sexual function was preserved in all patients. The WATER trial was able to directly compare Aquablation to TURP in a prospective manner across 17 different centers. 11 This double blind, randomized controlled trial include 181 patients. The goal of the trial was to assess Aquablation and TURP in a non- inferiority trial using composite endpoints for safety and efficacy. There was no significant difference seen in overall mean operative time, but resection time was significantly less with Aquablation. The group looked at 3 months postoperative safety data as well as 6 months postoperative IPSS scores. The primary safety endpoint was defined as a persistent Clavien- Dindo grade one event, or a Clavien-Dindo grade two or higher event. At 3 months, safety data showed Aquablation to be non-inferior to TURP. Additional analysis showed Aquablation to be superior to TURP Tokarski ET AL. 18