Editorial

Aquablation is not newfound; it was used ex vivo in animal models with a new type of water-jet dissector. This was conducted later in vivo to be compared with electric cautery section. Afterward its usage in partial nephrectomy was reported [1]. Furthermore, waterjet hydrodissection for removing bladder tumors was also utilized [2]. Gilling et al reported in 2016 the first study of Aquablation in benign prostatic hyperplasia in humans [3]. Aquablation underwent an evaluation leading to FDA approval in December 2017 after it has been shown that it was safe and efficacious in men with prostates between 30 and 80 cc [4].

The advantages of this technique include reduction in resection time compared with other endoscopic methods, as well as the potential to preserve sexual function [5]. As for the procedure, a 24-F hand piece probe similar to a rigid cystoscope is inserted into the prostatic urethra and secured using a bed-mounted rigid arm. Real-time prostate visualization is achieved by the use of bi-plane transrectal ultrasound. The surgeon uses a console to mark the target resection contour. Under the surgeon’s control, the ablation of tissue is robotically executed using a high-velocity waterjet to resect adenomatous tissue while avoiding the verumontanum and ejaculatory ducts. Following Aquablation, tissue samples can be collected for histopathology. Post-treatment management is done by inserting a standard urinary catheter, typically left in overnight, with bladder neck traction applied with continuous bladder irrigation [5]. As Gilling reported, most of the patients had their catheters removed on postoperative day 1, and most patients went home on the first postoperative day [5]. There were no blood transfusions and no significant changes in serum sodium. There was a statistically significant improvement in mean IPSS (International Prostate Symptom Score) from 23.1 at baseline to 8.6 at 6 months and Qmax (maximum flow rate) from 8.6 mL/s at baseline to 18.6 mL/s at 6 months. No cases of urinary incontinence or erectile dysfunction were reported [5].

In a 3-month U.S. cohort analysis, Aquablation appears to provide a strong surgical alternative in patients with benign prostatic hyperplasia due to larger prostate volumes. It has good functional outcomes, and relatively short operative time and shorter hospital stay, as well as acceptable complications and transfusions rates [6]. Aquablation clinically normalizes outcomes between patients of the < 100 cc and > 100 cc prostate cohorts. It is safe and effective in patients with large prostate glands (> 100 cc) with a smoother learning curve [7]. The rate of complications according to Clavien-Dindo classification was low (grade 2 or higher was 23%) [8]. Aquablation may be a good alternative for men who wish to maintain their ejaculatory function [9]. Future studies and long-term results from ongoing reports are required to secure aquablation position and acceptance as a true rival to other minimally invasive surgical techniques and the conventional TURP [10].

1.       Hubert J, Mourey E, Suty JM, Coissard A, Floquet J, et al. (1996) Water-jet dissection in renal surgery: experimental study of a new device in the pig. Urol Res 24: 355-359.

2.       Nagele U, Kugler M, Nicklas A, Merseburger AS, Walcher U, et al. (2011) Waterjet hydrodissection: first experiences and short-term outcomes of a novel approach to bladder tumor resection. World J Urol 29: 423-427.

3.       Chung ASJ, Woo HH (2018) Update on minimally invasive surgery and benign prostatic hyperplasia. Asian Journal of Urology 5: 22-27.

4.       Nguyen DD, Bhojani N, Zorn KC (2018) Furthering the external validity of Aquablation and implications for real world patients. LETTER TO EDITOR, World Journal of Urology 112: 33456789.

5.       Gilling P, Reuther R, Kahokehr A, Fraundorfer M (2016) Aquablation - image-guided robot-assisted waterjet ablation of the prostate: initial clinical experience. BJU Int 117: 923-929.

6.       Faysal A. Yafi, Christopher T. Tallman, Melvin L. Seard, Mark L. Jordan (2018) Aquablation outcomes for the U.S. cohort of men with LUTS due to BPH in large prostates (80-150 cc), IJIR: Your Sexual Medicine Journal 30: 209-214.

7.       Bhojani N, Nguyen DD, Kaufman RP. Jr., Elterman D, Zorn KC (2018) Comparison of < 100 cc prostates and > 100 cc prostates undergoing aquablation for benign prostatic hyperplasia. World Journal of Urology 2018.

8.       Misrai V. Barry Delongchamps N. Descazeaud A (2019) Aquablation for treating benign prostatic obstruction in small to medium-size glands: 6 months-outcomes of the first French registry. Eur Urol Suppl 18: 1918.

9.       Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M et al. (2018) Randomized Controlled Trial of Aquablation versus Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia: One-year Outcomes. UROLOGY 125: 169-173.

10.    Taktak S, Jones P, Haq A, Rai BP, Somani BK et al. (2018) Aquablation: a novel and minimally invasive surgery for benign prostate enlargement. Ther Adv Urol 10: 183-188.