If you are a man over 50, chances are you are experiencing some or all of the symptoms an enlarged prostate: weak urinary stream, stop and start urination, urinary urgency and frequency, straining to urinate, awakening at night to urinate, and hesitating to urinate. And you’re not alone: over 12 million men in America suffer with symptoms of an enlarged prostate. This condition, sometimes called benign prostatic hyperplasia or BPH, is the number 1 reason why patients visit the urologist.
In the past, urologists knew these symptoms to be bothersome, interfering with sleep and everyday activities, and occasionally leading to more serious conditions like visible blood in the urine, a urinary tract infection, or even an emergent visit to the hospital to have a catheter placed for urinary retention. But new evidence has shown that ignoring the signs and symptoms of an enlarged prostate can lead to something more serious: permanent bladder damage.
This occurs because the bladder, which is a muscular hollow sphere, has been contracting against the obstruction created by the enlarged prostate, and eventually over time the bladder muscle gives out, resulting in retention of urine and eventually in the need to have a permanent urinary catheter draining the bladder to a bag.
The treatment for BPH in the past has been oral medications, minimally invasive non-resective non-procedures, and surgical resection (removal) of tissue with electrocautery or lasers. The surgical procedure transurethral resection of the prostate, or TURP, has long been the gold standard for treatment of symptomatic enlarged prostate, against which all other treatment options are compared.
In the TURP procedure, an electrified loop of wire passed into the prostate via a scope is used under direct vision to carve out tissue into small pieces which are then flushed out through the scope. The electrode can both cut the tissue and cauterize bleeding points.
If the pills work, they have to be taken for life, or until they stop working, and are associated with milder side effects such as dizziness, nasal congestion, inability to ejaculate, loss of libido and erectile dysfunction, but also with more serious side effects of increased risk of stroke, dementia, depression, and increased risk of self-harm.
The minimally invasive procedures like microwave of the prostate, Urolift (implantation of metal tabs to open the prostate channel), and Rezum (injecting steam into the prostatic tissue) preserve sexual function but are not very effective at improving the urinary stream, as compared to TURP. The resective procedures including TURP, holmium laser enucleation of the prostate, and open or robotic prostate removal, result in excellent restoration of urinary stream, but at the expense of sexual function and urinary control.
Fortunately today there is a new outpatient surgical procedure that results in the prostatic channel being opened widely and permanently, without compromising erectile function, urinary control, or the ability to ejaculate. The procedure is called water jet ablation of the prostate, or Aquablation.
Approved by the FDA in 2020, Aquablation is performed under general anesthesia with the patient lying on his back. A transrectal ultrasound probe is first placed in the rectum and the images obtained of the prostate are used in mapping out the tissue that is to be ablated, or obliterated with the 10 PSI water pressure jet. Simultaneously, the Aquablation probe mounted onto a scope is placed in the urethra so that the procedure can be monitored both with ultrasound images and visually via the scope.
The mapping process preserves the bladder neck and urinary sphincter (to protect against post-operative incontinence), and the tissue around the ejaculatory ducts (to preserve ejaculation) while targeting the prostate tissue that protrudes into the bladder, and that obstructs the prostatic urethral channel. Once the prostate is mapped, the ablation is robotically controlled, starting at the neck of the bladder and proceeding to the urinary sphincter. The treated prostate tissue is essentially turned into dust, which is then flushed out through a scope. Two passes are made of the water jet through the prostatic urethra, then the probe is removed and any bleeding encountered at the neck of the bladder is treated with cautery.
The ultrasound probe is removed, a urinary catheter is placed, and the patient is usually sent home from the recovery room on the same day. The entire procedure takes less than one hour. The catheter is then removed in a few days.
The Aquablation procedure checks all the boxes as the ideal treatment for symptomatic prostate enlargement. In three separate clinical trials, the procedure was shown to be as effective in improving urinary flow rate and decreasing symptoms as TURP, but without the risks of retrograde ejaculation (semen passing into the bladder instead of out the urethra during intercourse), urinary incontinence, or erectile dysfunction.
The water jet of Aquablation uses no heat or electric current to remove the tissue, and thus no risk of damage to nerves and other structures deeper than the outside capsule of the prostate. TURP is generally reserved for prostate glands less than 100 grams in size (a normal prostate is 25 grams), but Aquablation has been shown to be effective in prostates 20 to 150 grams, and has been used successfully in even larger glands.
The transfusion rate for Aquablation is less than 1%, and the retreatment rate after the procedure is 6%, compared to 12% with TURP and up to 35% with Urolift. And finally, Aquablation can be performed on men who have had and failed Urolift implantation.
There are roughly 200 centers around the country that offer Aquablation, and we are fortunate to have the technology available here at Southwest Healthcare’s Rancho Springs Hospital in Murrieta.
Surveys show men want a long-lasting and effective treatment for BPH that does not jeopardize their sexual function and does not require taking lifelong medications. If you’ve been putting off treatment of your enlarged prostate, or if you would like to free yourself from prostate medicine prescription use, or if you’ve had a less invasive treatment for BPH and your symptoms either recurred or did not resolve, Aquablation may be right for you.
