4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 BPH. Some authors have advocated for selective electrocauterization in conjunction to Aquablation to minimizepostoperativebleeding. Gloger et al performed a retrospective review of patients who underwent Aquablation followed by selective cauterization of the bladder neck and resection bed and compared them to those patients undergoing HoLEP. 14 They found that despite the added step of electrocauterization, operative times were still shorter in the Aquablation group compared to the HoLEP cohort. Return to the OR for bleeding within 6 weeks was similar between the two groups at 13.6% and 9.8% for Aquablation and HoLEP respectively. The average drop in Hgb was also similar between the twogroups (1.3mg/dLforAquablation and 1.22 mg/dL for HoLEP), with no patients undergoing Aquablation requiringblood transfusion andone patient in the HoLEP group requiring transfusion. Durability and adverse events The same cohort used in the original WATER trial was followed out to 12 months post procedure with a purpose of investigating the safety and efficacy of this procedure compared to TURP. 15 The notable findings of this study were that TURP and Aquablation had similar improvements in Qmax, similar decrease in serumPSAlevels, and similar low re-treatment rates at 12months. TheAquablation cohort had2.6%of patients who underwent reoperation compared to 1.5% in the TURP group which was not statistically significant. The study also analyzed results in patients who had larger than 50 mL prostates before treatment. 16 This subgroup analysis favored Aquablation for both the safety and efficacy endpoints. There was no difference in average procedure time (33minutes forAquablation versus 36minutes for TURP), butAquablation did have a significant difference in resection time (4 minutes versus 27 minutes). Additional analysis of this larger prostate size subgroup showed that on average, there was a greater drop in postoperative hemoglobin in the Aquablation group compared to those patients undergoing TURP, which was statistically significant. The Aquablation group had one patient that required blood transfusion with, no patients requiring transfusion in the TURP group. The patients in the WATER II trial were followed up to 6 months. 17 When analyzing adverse events at 6 months, 22% of the patients had experienced a Clavien- Dindo grade II event, 14% a grade III event, and 5% a grade IVevent. Qmax increased from8.7 cc/s at baseline to 18.8 cc/s at 6 months. PVR decreased from 131 mL to 47 mL at 6 months. QoL scores decreased from 4.6 at baseline to 1.4 by 6months. PSAshoweda 44%reduction on averagewhile TRUS volume showed a 42%reduction compared to baseline. With regard to the patients’ postoperative sexual function, MSHQ-EjD scores at 6 months continued to show slight improvement compared to baseline though not as pronounced as at 3 months. IIEF-5 scores improved by an average of 0.1 at 3 months and an average of 0.7 at 6 months. Nguyen et al compared the results of the original WATER trial with those ofWATER II once 12monthdata was available. 18 Specifically they stratified patients into prostate sizes between 30 g and 80 g and those patients with prostates between 80 g and 150 g. These authors noted that there was no relationship between IPSS scores and prostate volume across both studies. They did however note that therewas an inverse relationship between prostate size and Qmax at baseline and patients had higher PVRs with increased prostate size. There was no difference between the two groups when comparing postoperative IPSS scores or Qmax at 1, 3, 6, or 12months. Therewas a significantly higher decrease in PVR when comparing the two groups, however this could be attributed to the larger prostates seen in the WATER II trial. Transient Clavien-Dindo I events were similar between both groups. Persistent Clavien-Dindo I events were more common in theWATER II trial (16% versus 8%) and were mostly related to anejaculation. Clavien-Dindo grade II or higher events were more common inWATER II. Operative times were 4minutes longer in the cohort of patients with larger prostates. Based on this comparison the authors were able to conclude that with short term follow up Aquablation provides a safe and efficacious treatment for both small to moderate gland as well as large gland BPH. Recently, 3-year follow up data has become available for the patients in the original WATER trial. Three years of follow up was achieved in 87% of Aquablation patients and 85% of TURP patients from the original study. The mean percent reduction in IPSS scores was 64% and 61% in the Aquablation and TURP groups respectively. In patients with prostates larger than 50 mL, there was an average of 3.5 points greater reduction in IPSS for those who underwent Aquablation. Changes in ejaculatory function, measured byMSHQ-EjD, also favoredAquablation as seen in the original study. At 3 years, the improvement from baseline in Qmax, PVR, and reduction in PSA persisted and were statistically similar between both groups. The 3-year retreatment rates were 4.3% and 1.5% in theAquablation and TURPgroups respectively, with no interventions happening beyond 20 months. The results of this continued follow up study demonstrate the durability of Aquablation compared to TURP at medium term follow up. Tokarski ET AL. 20