This was followed by the WATER II trial, a single-arm, safety, and feasibility study of Aquablation in men with prostates between 80 and 150 grams. Interestingly enough, our current data is most comparable to that of the WATER II trial as the mean prostate volume of the trial was 107 compared to ours at 110 mL.3 Whether you are assessing the WATER trials or our current series, they all report similar rates of IPSS reduction, Qmax improvement, and minimal sexual or ejaculatory side effects. These results have been confirmed in recent 5-year follow-up data showing a sustained response and a retreatment rate as low as 3.7%.4
Several aspects of the Aquablation technology make it an attractive treatment option for men with BPH, which were highlighted in our report. As stated above, men treated with Aquablation have sustained a reduction in IPSS and improvement in Qmax. Secondly, compared to other treatment modalities such as simple prostatectomy and HoLEP, Aquablation has a relatively short learning curve with consistent surgeon reproducibility supported by the fact that 14 out of 17 sites in the WATER trial and 9 out of 16 sites in the WATER II trial had no prior experience with Aquablation before starting the trial. Additionally, all of the aforementioned studies including our own demonstrate similar objective response rates to treatment supporting the fact that surgeon experience and comfort level may not be as important of a technical consideration as compared with other available technologies. Undoubtedly, this is a benefit for patients and trainees alike. Thirdly, sexual and ejaculatory side effects were minimal putting Aquablation in the same class of options as Rezum or Urolift for patients whose main goal is preservation of sexual function. Lastly, Aquablation treatment seems to be relatively size-independent. In our series, we treated glands up to 330 grams without any compromise in treatment response.
Complications are a reality of any surgical treatment and remain a consideration in Aquablation. In our series, complications included urinary tract infection (11%), bleeding requiring blood transfusion (3%), and retreatment (4%). One complication that was improved upon over the course of the case series was hemorrhage and blood transfusion rate. This was done through circumferential cauterization of the bladder neck after Aquablation resection. During this maneuver, it is important to visualize the anterior aspect of the prostate gland in case there is any residual tissue that may cause further obstruction. As Aquablation is still a novel therapy, we are hopeful that further improvements will be made to make this treatment modality safer for patients.
Overall, our study shows sustained treatment response with Aquablation for men with symptomatic BPH. The benefits of this novel technology are persistent response with low retreatment rates, surgeon-to-surgeon reproducibility with a low learning curve, preservation of sexual function, and the ability to be conducted in large prostate glands. Lessons learned included broader post-Aquablation coagulation to reduce bleeding, focusing on anterior tissue with electrosurgery at the time of Aquablation, and changing antibiotic regimens. As this technology continues to be adopted in both high and low-resource environments, we are encouraged by the gambit of surgical options available to patients with symptomatic BPH.
Written by: Olamide O. Omidele, MD & Steven A. Kaplan, MD, Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
References:
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