For example, in the patient who desires an office-based procedure (with a prostate between 30 and 80 cc and favorable anatomy) who is willing to accept a higher retreatment rate for the sake of minimal invasiveness and higher chance of preserving ejaculatory function, prostatic urethral lift or water vapor therapy may be preferred. On the other hand, in someone with a larger prostate, or with an obstructing median lobe, then a more invasive approach with prostatic resection may be more appropriate.
In general, more invasive treatments are associated with higher risk and higher success than minimally invasive treatments. For example, office-based surgery has the lowest risk of sexual side effects, but the highest retreatment rates. Extirpative surgery, such as simple prostatectomy has the greatest success rate (based on IPSS and uroflow), but at the cost of higher rates of urinary and sexual side effects.
Resective therapies have generally been recommended for prostates up to 100 cc in volume, although some surgeons may offer photovaporization for extremely large glands, as the risk of TUR-syndrome is indeed low in the absence of bleeding. However, vaporization of large prostates is associated with long surgical times and is therefore prone to its own unique risks related to prolonged anesthesia and lengthy time in lithotomy position.
Until the advent of water jet ablation, treatment for very large prostates greater than 100 cc was best- accomplished with laser enucleation or simple retropubic or suprapubic prostatectomy. However, the difficult learning curve for endoscopic enucleation and robotic simple prostatectomy (which was only recently FDA-cleared), and the higher rates of incontinence with those procedures compared to resection, as well as the ubiquitous complication of retrograde ejaculation, has made these more invasive procedures relatively unpalatable for patients.
Water jet ablation, with its robotic assistance, allows the resection to be done in less than 10 -20 minutes in nearly all cases, and sparing of the distal tissue near the verumontanum allows preservation of ejaculation in > 90% of cases.1 This “size-independent” procedure grants patients the option for a resective surgery regardless of prostate volume.
With regard to retention, in our series prostates tend to be larger in those patients compared to those who are able to void spontaneously. Thus robotic assistance is especially helpful for the sake of operative speed. The literature is generally limited regarding the efficacy of prostatic urethral lift in men with urinary retention, and water vapor therapy has a success rate of < 80%, roughly equivalent to that of a simple trial of voiding in the setting of alpha-adrenergic blockade.2,3 And while TURP and laser vaporization and enucleation are associated with a very high success rate in patients with retention, TURP and laser ablation are generally limited to prostates < 100 cc, endoscopic enucleation is beyond the skillset of many urologists, and all are associated with high rates of sexual dysfunction due to anejaculation or retrograde ejaculation.4-9 Finally, the literature demonstrates that prostatic artery embolization appears generally less efficacious than simple voiding trials.11
In our study, we showed high efficacy for the novel water jet ablation therapy for men with urinary retention, with 98% success in achieving voiding without catheterization. In men with and without urinary retention, complication rates were similar to those expected with TURP, with an acceptably low rate of transfusion (1%), urethral meatal stenosis (5%), and reoperation rate for bleeding (2%).
In summary, we find that water jet ablation is appropriate for men with and without urinary retention, regardless of prostate size. The quick surgical time and preservation of sexual function represent an advantage over TURP and laser surgery, especially in men with large prostates. Men with a history of retention are more likely to fail their initial postoperative voiding trial compared to those who were voiding prior to surgery (29% versus 7%). We therefore recommend that a catheter stay in for 2 days postoperatively (identical to our protocol for TURP) for those without preoperative retention, and for 7 days in those who were catheter-dependent prior to surgery.
Written by: Claire S. Burton, MD, Amy D. Dobberfuhl, MD, & Craig V. Comiter, MD
Department of Urology, Stanford University School of Medicine, Stanford, CA
References:
- Gilling JP, Bartber N, Bidair M, et al: Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol. 2022;29:10960-10968.
- McVary KT, Holland B, Beahrs JR. Water vapor thermal therapy to alleviate catheter-dependent urinary retention secondary to benign prostatic hyperplasia. Prostate Cancer Prostatic Dis. 2020;23:303–308.
- Bassily D, Wong V, Phillips JL, Fraiman M, Bauer R, Dixon CM, et al. Rezūm for retention-retrospective review of water vaporization therapy in the management of urinary retention in men with benign prostatic hyperplasia. The Prostate. 2021;81:1049–1054.
- Huang LK, Chang YH, Shao IH, Lee TL, Hsieh ML. Clinical Outcome of Immediate Transurethral Surgery for Benign Prostate Obstruction Patients with Acute Urinary Retention: More Radical Resection Resulted in Better Voiding Function. J Clin Med. 2019;22;8:1278-1286.
- Djavan B, Madersbacher S, Klingler C, Marberger M. Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable? J Urol. 1997;58:1829–1833.
- Ghalayini IF, Al-Ghazo MA, Pickard RS. A prospective randomized trial comparing transurethral prostatic resection and clean intermittent self-catheterization in men with chronic urinary retention. BJU Int. 2005;96:93–97.
- Radomski SB, Herschorn S, Naglie G. Acute urinary retention in men: a comparison of voiding and nonvoiding patients after prostatectomy. J Urol. 1995;153:685–688.
- Goueli R, Meskawi M, Thomas D, Hueber PA, Tholomier C, Valdivieso R, et al. Efficacy, Safety, and Durability of 532 nm Laser Photovaporization of the Prostate with GreenLight 180 W XPS in Men with Acute Urinary Retention. J Endourol. 2017;31:1189–1194.
- Aho T, Finch W, Jefferson P, Suraparaju L, Georgiades F. HoLEP for acute and non-neurogenic chronic urinary retention: how effective is it? World J Urol. 2021;7:2355–2361.
- Baboudjian M, Alegorides C, Fourmarier M, Atamian A, Gondran-Tellier B, Andre M, et al. Comparison of water vapor thermal therapy and prostate artery embolization for fragile patients with indwelling urinary catheters: Preliminary results from a multi-institutional study. Progres En Urol J Assoc Francaise Urol Soc Francaise Urol. 2022;32:115–120.