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Background: Surgical options are limited when treating large (>80 cm3) prostates for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Open simple prostatectomy remains the most common procedure performed for large prostates. There is a need for novel surgical approaches with shorter learning curves and effective treatment. Aquablation could be this novel tool. Objective: To compare the outcome of Aquablation for 30–80-cm3 prostates with the outcome for 80–150-cm3 prostates at 2-yr follow-up. Design, setting, and participants: We used data from two trials. WATER is a prospective, double-blind, multicenter, international clinical trial comparing the safety and efficacy of Aquablation and transurethral resection of the prostate in the treatment of LUTS/BPH in men aged 45–80 yr with a prostate of 30–80 cm3. WATER II is a prospective, multicenter, single-arm international clinical trial of Aquablation in men with a prostate of 80–150 cm3. Intervention: Aquablation, an ultrasound-guided, robotically executed waterjet ablative procedure. Outcome measurements and statistical analysis: We compared 24-mo outcomes between 116 WATER and 101 WATER II study subjects. Student’s t test or a Wilcoxon test was used to compare continuous variables and Fisher’s test for categorical variables. Results and limitations: The International Prostate Symptom Score (IPSS) reductions at 24 mo was 14.5 points for WATER and 17.4 points for WATER II (p = 0.31). At baseline, the maximum urinary flow rate (Qmax) was 9.4 and 8.7 cm3/s in WATER and WATER II, improving to 20.5 and 18.2 cm3/s, respectively (p = 0.60) at 24 mo. Improvements in both IPSS and Qmax were immediate and sustained throughout follow-up. At 2 yr, the surgical retreatment rate was 4% in WATER and 2% in WATER II. Conclusions: Aquablation is effective in patients with a prostate of 30–80 cm3 and patients with a prostate of 80–150 cm3 treated for LUTS/BPH, with comparable outcomes in both groups. It has low complication and retreatment rates at 2 yr of follow-up, with durable improvements in functional outcome. Patient summary: Outcomes of Aquablation for both small-to-moderately-sized and large prostates are similar and sustainable at 2 yr of follow-up.

Benign prostatic hyperplasia (BPH) is a highly prevalent condition among aging men with significant negative impacts on quality of life. Although multiple surgical treatment modalities exist, there is an ongoing search for minimally invasive techniques to reduce hospital stays and adverse effects without compromising good functional outcomes. Aquablation is a novel minimally invasive surgical technique that combines robotic precision with heat-sparing ablation of obstructing prostate tissue. We describe the setup and mechanism of action of aquablation. A comprehensive literature search for clinical trials and recent meta-analyses was conducted and functional outcomes and adverse effects across multiple studies are summarized here. Aquablation produces comparable (if not superior) outcomes in terms of reduced International Prostate Symptom Score, improved Qmax (comparison of maximum flow velocity), and lower postvoid residuals to transurethral resection of the prostate. These findings are consistently reproduced across multiple clinical trials, including those conducted in the private sector. One major benefit of aquablation is that the risk of injury to the ejaculatory ducts appears to be significantly lower, as evident from the low percentage of cases of postoperative anejaculation issues. Adverse effects are rare, and the most significant one to mention is blood loss requiring transfusion. At present, the overall cost of aquablation is still higher than other methods of treating BPH and this is due to intraoperative and equipment costs. Postoperative care is no more expensive than other methods of BPH treatment. In conclusion, aquablation is a safe and effective surgical modality for the treatment of BPH. It can be offered as an alternative to other surgical modalities for those who wish to spare ejaculatory function. The procedure itself can be easily taught. With further development of this novel technology and increased availability, there is the potential for it to become a much more cost-effective method for surgical treatment of BPH. [ABSTRACT FROM AUTHOR]

Purpose We compared the safety and efficacy of Aquablation and transurethral prostate resection for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia. Materials and Methods In a double-blind, multicenter, prospective, randomized, controlled trial 181 patients with moderate to severe lower urinary tract symptoms related to benign prostatic hyperplasia underwent transurethral prostate resection or Aquablation. The primary efficacy end point was the reduction in International Prostate Symptom Score at 6 months. The primary safety end point was the development of Clavien-Dindo persistent grade 1, or 2 or higher operative complications. Results Mean total operative time was similar for Aquablation and transurethral prostate resection (33 vs 36 minutes, p = 0.2752) but resection time was lower for Aquablation (4 vs 27 minutes, p <0.0001). At month 6 patients treated with Aquablation and transurethral prostate resection experienced large I-PSS improvements. The prespecified study noninferiority hypothesis was satisfied (p <0.0001). Of the patients who underwent Aquablation and transurethral prostate resection 26% and 42%, respectively, experienced a primary safety end point, which met the study primary noninferiority safety hypothesis and subsequently demonstrated superiority (p = 0.0149). Among sexually active men the rate of anejaculation was lower in those treated with Aquablation (10% vs 36%, p = 0.0003). Conclusions Surgical prostate resection using Aquablation showed noninferior symptom relief compared to transurethral prostate resection but with a lower risk of sexual dysfunction. Larger prostates (50 to 80 ml) demonstrated a more pronounced superior safety and efficacy benefit. Longer term followup would help assess the clinical value of Aquablation. [ABSTRACT FROM AUTHOR]

Purpose We sought to establish the safety and effectiveness of aquablation, a novel, image guided, robotic assisted, water jet tissue ablation technology, for the treatment of benign prostatic hyperplasia. Materials and Methods We performed a prospective, single arm, multicenter trial at a total of 3 centers in Australia and New Zealand with 1-year followup. Participants were men 50 to 80 years old with moderate to severe lower urinary tract symptoms as determined by urodynamics. All patients underwent aquablation under image guidance. Primary end points included procedural and perioperative safety. The main clinical end point was the change from baseline in I-PSS (International Prostate Symptom Score). Other secondary end points included uroflow measures, prostate volume on transrectal ultrasound and detrusor pressure. Detrusor pressure at maximum flow was only measured at 6 months. Results A total of 21 men underwent aquablation at a mean age of 69.7 years (range 62 to 78). Prostate volume was 57.2 ml (range 30 to 102). Procedural duration averaged 38 minutes with a mean aquablation treatment time of 5 minutes. All but 1 subject were catheterized for 1 day only and 19 of 21 were discharged home the day after the procedure. Detrusor pressure at maximum flow decreased from 65 cm H 2 O at baseline to 39 cm H 2 O at 6 months (p <0.0027). Prostate volume decreased from 57 ml at baseline to 35 ml (p <0.0001). Mean I-PSS score improved from 23.0 at baseline to 6.8 at 12 months (p <0.0001) and maximum urinary flow increased from 8.7 to 18.3 ml per second (p <0.0001). There were no important perioperative adverse events. No urinary incontinence developed and sexual function was preserved postoperatively. Conclusions This phase II study provides early evidence to support the safety and effectiveness of aquablation for symptomatic benign prostatic hyperplasia. [ABSTRACT FROM AUTHOR]

At a wavelength of 2140 nm, the holmium:YAG (Ho:YAG) laser can be used for incision, ablation and resection of prostatic tissue. This laser has revolutionised the surgical management of benign prostatic hyperplasia (BPH) in our institution. Five different techniques have been utilised in evolving the current techniques using the Ho:YAG laser either alone or in combination with neodymium:YAG (Nd:YAG laser for the surgical management of BPH. The clinical outcome of 664 patients undergoing these procedures is presented. Enucleation of the prostatic adenoma using the holmium laser energy is the most common procedure presently performed at our institution for the surgical management of BPH. A mechanical tissue morcellator appears to be the most efficient way to remove prostatic tissue, once enucleated, from within the bladder. [ABSTRACT FROM AUTHOR]