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BackTable / Urology / Article
Aquablation of the Prostate: A Practical Procedure Guide
Javier Prieto III • Updated Jul 19, 2024 • 220 hits
Aquablation is an emerging treatment for patients with BPH (benign prostatic hyperplasia). The procedure utilizes high-pressure water jet technology to remove prostatic tissue with accuracy and precision, with recent clinical data indicating positive outcomes. Aquablation is performed in conjunction with transrectal ultrasound, which aids in prostate targeting and depth planning throughout the procedure.
Dr. Ali Kasraeian, a pioneer in the development of aquablation, provides a step-by-step surgical guide with Dr. Jose Silva on how to carry out aquablation procedures successfully.This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• The initial stages of aquablation rely heavily on transrectal ultrasound to map the prostate and protect critical structures such as the bladder neck and ejaculatory ducts. Typically, the operation involves two four-to-five-minute water jet sessions to remove prostate tissue.
• Aquablation can be particularly challenging when dealing with the median lobes of the prostate due to their proximity to the posterior wall of the bladder. Careful ultrasound planning helps ensure that only BPH-related tissue is removed, minimizing the risk of bladder damage.
• Prostate depth planning is a crucial aspect of aquablation. Precise preparation allows urologists to target excess tissue while avoiding the transitional zone for patient safety. The depth of the water jet is generally adjusted according to the size of the prostate.
Table of Contents
(1) Aquablation Procedure Walkthrough
(2) Managing Median Lobes During Aquablation
(3) Prostate Depth Planning in Aquablation
Aquablation Procedure Walkthrough
Starting an aquablation procedure involves using transrectal ultrasound to obtain an exterior view of the prostate and evaluate the transitional zone. Ultrasound plays a significant role during the early planning stages of the procedure. Ideally, the bladder neck and ejaculatory ducts are preserved while maneuvering around the target portion of the prostate. After careful planning and preparation, a cystoscopic view is obtained to incorporate water jet technology, allowing for greater accuracy and precision. Only the center of the jet stream has the strength to ablate tissue, making accidental removal of surrounding tissue very unlikely.
Each water jet session typically takes four to five minutes, with most aquablation procedures requiring two passes to eliminate all unwanted prostate tissue. Therefore, most water jet ablations are completed in eight minutes or less. The next step involves inserting a resectoscope to remove unnecessary tissue at the bladder neck, allowing for focal bladder neck cautery to be performed to reduce prostate bleeding after ablation. In the past, aquablation was done without focal bladder neck cautery, which caused concern among urologists due to the lack of a method to stop possible bleeding after the surgery.
[Dr. Kasraeian]:
For the audience, the way the technique is done now, so the way an aquablation procedure is done, you're using a transrectal ultrasound to allow for the planning of the aquablation procedure. Basically, the ultrasound allows you to see and evaluate the prostate from outside and really look at the transitional zone and the portion that you're going to open up. That allows you for the planning of what the water jet is going to actually open up and what you're going to preserve. You preserve the bladder neck, you're in front of essentially where the sphincter mechanism and the verumontanum is. You have a virozone or a butterfly cut that you plan so that you can try to preserve where the ejaculatory ducts are draining and you stay away from that allows for the strong preservation numbers that you have in terms of anagrade ejaculatory preservation. That's the planning aspect of things that you have. That is the ultrasonic portion of the planning stage.
Then you have a cystoscopic view that you have where the water jet technology is incorporated into the cystoscopic view. With that combination, you have a lot of precision and accuracy in terms of the planning stage. The water jet then opens up. The prostate is a very powerful water jet delivery that essentially ablates and opens up the channel. The water jet has about a 2.4 centimeter throw of the. water at the lower portion of things, which again, you can plan the depth of your planning.
At the lower portions of it, the strength of that water jet is very weak so that it doesn't hurt the tissue at the lower depths of your planning. What's nice about that is that you can feel confident that you're not going to hurt the tissue at those areas. Actually, you have control throughout the procedure to either stop the water jet or secondarily decrease or increase the height, but you cannot go beyond the limits of your planning, so that can prevent injury and things of that nature, which also is good.
Once you finish the water jet portion, which usually takes less than four to five minutes with each pass, and in most of these studies, the total ablation time or water jet ablation time is about eight minutes to nine minutes, and really most of them have been eight minutes or less. Then you actually go in with a resectoscope similar to a TURP and you do a bladder neck cautery, like a focal bladder neck cautery, where you do a little bit of a resection of fluffy tissue that remains at the bladder neck. You unroof that and you point coagulate the tissue so that you can stop any bleeding at that point.
Early in our experience, we did not do that. Basically, you went and did the water jet, did two passes, put a catheter in, and then you basically put tension with this catheter tensioning device. Basically, what a lot of times would happen is-
[Dr. Jose Silva]:
Pray.
[Dr. Kasraeian]:
You would pray. Initially, the first cases we did was very interesting. You'd do that, a lot of times you put the scope in there and you'd flush and irrigate for a bit. A lot of times you'd look and you're like, "What on earth is it?" Like you'd said, you'd pray during that, you'd flush and irrigate, and then you'd put the catheter in and you'd put tension. While the patient's asleep, it looked great and everything would clear up. Then they'd wake up and it looked markedly different, or you'd go in the recovery room. And then I remember I worked with my dad. One of the cases, he came over to see what was going on, and I really never seen his face like that either before or ever since.
But amazingly, the patient stood well and the bleeding would stop, and even with that aspect of things. One of my earliest patients was actually a bladder cancer patient. I got to scope them every three to six months for years. Obviously, we're at five years now, so the frequency of those cystoscopies have gotten longer, but such a beautiful, wide open channel and a significant decrease in his voiding symptoms and how quickly he improved and the maintenance of that improvement was quite impressive from that standpoint.
However, very quickly, we learned from those experiences and began the bladder neck cautery and that really turned things around in terms of, again, from my experience, fortunately, we did not have much transfusion or take backs or people returning to the hospital or anything like that.
But the comfort level of not having to worry about that and just being able to go home and sleep at night and being concerned and being able to answer questions that people would have regarding the concerns regarding the bleeding and the transfusions regarding to that, both in terms of the data, but even anecdotal conversations were able to improve with that change in the technique.
[Dr. Jose Silva]:
Definitely, I think for me has been the challenge, or what I call the challenge, but the difference because I do see a lot of GreenLight, and I'm used to not seeing blood during prostate procedures. Every time that I did a TURP, I said, "Why am I still doing this?" When I go in after the aquablation, it bleeds. Afterwards, when you reach that area of the bladder neck that you start cautery and then you stop the bleeding, then the big hole. Also on the ultrasound, you can appreciate the big defect that you get from the aquablation.
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Managing Median Lobes During Aquablation
More than 90% of aquablation procedures require two passes with the water jet to eliminate excessive tissue. In some cases, more than two passes are necessary due to increased prostate size or abnormal pelvic positioning. During the procedure, it is critical to be mindful of large median lobes, as damage can occur at the bladder neck during ablation. Hefty median lobes can settle along the posterior wall of the bladder, putting surrounding bladder tissue at risk of being ablated. Protecting the bladder neck from ablation should be a priority to ensure successful cautery. Therefore, ultrasound is used again to identify the position of the bladder neck relative to the median lobe and confirm that only the desired areas of the prostate will be ablated. Additional planning before aquablation is not required in all cases, as not all patients have prostates with large median lobes.
[Dr. Jose Silva]:
In terms of going back to the technique, how aggressive are you in terms of tissue removal? Because right now, I haven't done that many cases. I'm still sticking in the upper part of the prostate, just very parallel to the prostate. I'm not doing any angulation or anything, but are you doing many passes? How many passes out with different angles you're doing?
[Dr. Kasraeian]:
So with the water jet portion of things, the vast majority, I'd say more than 90%, 95% of our water jet ablations are about two passes. It really depends on the size and also the shape of the prostate. We recently did a 457-gram prostate. When you're doing that, it really is dictated by the shape of the prostate. This was almost like two different prostates. One part of his prostate was almost entirely at the proximal into the bladder. It was amazing that this guy, for years up until he went into retention, was able to urinate at all. It's unbelievable. Then you had the intraprostatic component of the prostate.
We basically had one plan of doing basically almost two and a half to three passes with that giant portion of things within the prostate, and then almost like two or two and a half passes within the intraprostatic component of things. That was the one case we've had where he did about five passes. It was really like four and a half. We've had some cases where we've done three passes, but the vast majority-- We've had one case where we did four, which is a very large prostate. Most of them, they're two passes.
You're very careful if you have these big median lobes. You're careful how to plan it so you don't do too much at the bladder neck, so you actually basically cut it off. Now you have this big giant median lobe floating around in the bladder, because then you have to essentially figure out how to then resect that floating around median lobe and make sure you don't back wall the bladder. We're very careful in how to do those things so that you don't set yourself up for having to do more later on.
Sometimes when people have a median lobe, you can actually plan on how to safely thin it out. Then when you're doing that bladder neck cautery, you can then actually then safely resect that portion and be safe to make sure you don't injure or give too much water jet energy at the trigone from that standpoint. If I'm worried about what that relationship between the bladder neck and the median lobe and the trigone is, you can always go and take a look with a cystoscope right before and get an idea of what that looks like.
That really takes a few minutes beforehand if you need to do that. Those things can give you some idea of what the anatomy looks like so you can plan how to better assess the planning of the bladder neck versus the intraprostatic portion of things. Even with that, the vast majority of our plans are two plans. Sometimes you can drop the hand piece so that you can better include the power that you need so that you can better deliver the energy in a way that more effectively opens up the channel.
[Dr. Jose Silva]:
You decide that based on the ultrasound?
[Dr. Kasraeian]:
Based on the ultrasound and then also the relationship with what you're looking at intraoperatively. I think that's where the elegance and the beauty of this procedure really shines, is that it allows you some artistry in terms of how to deliver the technology in a way that can optimize your end delivery of the outcomes you're hoping for. Every case is different, and every case, every prostate has a little subtlety in terms of the difference of it. With this, it almost makes you want to use an ultrasound every time you do a TURP or anything like this, because you can actually see what's going on.
I had one case one time who-- this was a patient who I met who had had two UroLift procedures done and was still in retention with something like an 80-some gram prostate. I was trying to make a decision whether to do the aquablation first or get the UroLift implants out first. He was really very passionate about getting all the UroLift implants. I just imagined going and dealing with that afterwards, it would be a little bit more challenging. When I went and did a scope beforehand, there were a lot of the implants just right in front of my face and you could see them with the ultrasound. I'm like, "Okay, let me start resecting it."
The trouble with the TURP is, once you start, it's tough to stop. I'm like resecting and resecting. Next thing you look at the ultrasound and the whole prostate is wide open. I looked at my aquablation rep, they're wonderful about being in there and they're very helpful. We looked at each other and looked at the ultrasound and we were like, "Well, what on earth are we going to aquaplate?" We ended up just stopping because the TURP left us with this beautiful wide open channel. I could have probably done the same thing with the aquablation in eight minutes as opposed to the amount of time it took me to open that whole thing up and get all the UroLift implants. Then I probably wasted a few bipolar loops in the effort, from that standpoint.
[Dr. Jose Silva]:
I already have done a few aquablations after UroLift. Yes, I do the aquablation, and then actually the rep told me, "Hey, don't do like Kasraeian."
[Dr. Kasraeian]:
Honestly, but I learned from that to not ever do that again. [laughs]
Prostate Depth Planning in Aquablation
The maximum depth of an aquablation water jet is 2.4 centimeters, but many prostate cases require less. The depth of the water jet is usually directly correlated with the size of the prostate. While smaller prostates do not require as much depth, they can sometimes be more complex due to their transitional zones. Smaller prostates have smaller transitional zones, which necessitates more careful planning due to the higher chance of error. Water jets are equipped with lower-pressure options to address this issue, allowing urologists to deliver gentle streams of water onto the prostate to determine its orientation. Gaining experience with these techniques and mastering transrectal ultrasound equips urologists with the necessary tools to understand the varying anatomy of prostates and perform successful aquablation procedures.
[Dr. Jose Silva]:
In terms of the depth, that is the 2.8 that you mentioned, do you try to stick to that or you sometimes have to go deeper?
[Dr. Kasraeian]:
The depth of the water jet, the maximum that it can go is 2.4 centimeters. When you're planning, you can't really plan further than that, so that maximizes that. A lot of times you're actually less than that. Based on the size of the prostate, so imagine you have a 30-gram prostate, you're going to be much, much less than that. I actually find, honestly, smaller prostates are a lot more difficult to plan and take a little bit longer to plan than bigger prostates because they have a smaller transitional zone.
You have to have a median lobe, and so the median lobe is one size and then you have a smaller transitional zone within the prostate. You have to be a bit smart in terms of figuring out how to do all that stuff and not affect the outer portions of things. Sometimes large prostates are much easier to plan from that standpoint. Then you have to be mindful of planning upwards where the bladder neck is so you don't undermine the trigone with the water jet aspect of things.
Then when you're approaching upcoming to the verumontanum and things like that, the water jet slopes. Sometimes you can use the-- There's a prime button that's called on the pedal, where it gives a very soft hit of the water jet that you could do within the prostate and it identifies the planes within the prostatic urethra a bit and you can figure out what those different planes between the zones of the prostate sometimes, and that can help you identify how to plan things.
A lot of little things you can do to help the subtleties of the anatomy of the prostate, which as someone that does a lot of cancer therapies, is using ultrasound and other things, it's been very nice to understand and learn more about prostate ultrasound with the aquablation that you can apply to other things as well.
[Dr. Jose Silva]:
Definitely I'm learning about that functional-wise, how the prostate-- that area of the sphincter, so it's been good for me.
[Dr. Kasraeian]:
Tell me, what are your thoughts in terms of your early experience for this, in terms of going from thinking about this as a concept to the application to your patients?
[Dr. Jose Silva]:
I'm very excited. Definitely, the patients are doing great. They have great flow. I guess, personally, just that part when going in and everything is blurry. Last time I started doing that, just doing the irrigation first, waiting for everything to settle and then going in. Definitely, if you go in directly with the cystoscope, you're not going to see anything. That has changed, but definitely very excited about the technology.
One other thing is that, even though you are mapping the prostate, I think it's not that user-dependent, because you're going to get a whole base on the mapping. With GreenLight, sometimes it's more subjective, like you think that you might have a good hole, the patient might be waiting fine for two or three years, and then suddenly you go in and it's like nothing happened. Hopefully with this technology, it will stay open for a long, long time.
Podcast Contributors
Dr. Ali Kasraeian
Dr. Ali Kasraeian is a private practice urologic oncologist in Jacksonville, Florida.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 13). Ep. 142 – Aquablation: Expanding BPH Management Options [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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