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BackTable / Urology / Article
Aquablation Essentials: Patient Candidacy & Procedure Protocols
Javier Prieto III • Updated Jul 21, 2024 • 489 hits
Aquablation is a relatively new benign prostatic hyperplasia (BPH) treatment that is growing in popularity. Offering a unique mechanism of action for prostate treatment, aquablation is a minimally invasive, ultrasound-guided procedure that uses high-pressure water jet technology to remove prostate tissue. When given the option, patients may prefer aquablation over more invasive treatment options, such as prostatectomy. Five-year data collection has demonstrated that aquablation is effective in alleviating BPH symptoms and limiting procedure-related complications that can occur with other BPH treatments.
Florida urologists Dr. Ali Kasraeian and Dr. Jose Silva discuss the pre-, intra-, and postoperative measures for the aquablation procedure and risk factors to consider during patient workup. Acknowledging the multifaceted nature of BPH and the many factors that can influence aquablation outcomes, like surgical bleeding and the role of postoperative catheterization, can make the difference between a successful operation and an unsuccessful one.
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
• Anticoagulation and antiplatelet medications can disqualify patients seeking aquablation. Deliberate planning before and after surgery when handling these classes of medications is crucial in preventing bleeding and coagulation complications that at-risk patients can encounter.
• The standard pre-op for aquablation includes understanding how structures surrounding the prostate are affected in three-dimensional space and performing tests to measure urine flow. Intraoperatively, administering thromboxane during aquablations has become mainstream within the urological community due to its effectiveness in preventing excess bleeding for patients.
• Postoperative urinary retention can occur after aqaublation procedures, which is why inserting a Foley catheter after surgery is the universal protocol. The number of days that the Foley catheter should remain in place depends on various patient factors. Nonetheless, the goal is to avoid removing the catheter prematurely, which can harm the patient.
Table of Contents
(1) Aquablation Patient Candidacy
(2) Pre-Op & Intraoperative Measures for Prostate Aquablation
(3) Best Practices in Aquablation Post-Op Care
Aquablation Patient Candidacy
BPH patients considering aquablation for symptomatic relief and treatment must meet specific criteria before undergoing surgery. Evaluating a patient's candidacy for aquablation includes obtaining a comprehensive patient history to uncover health factors that can lead to complications during surgery and determine whether anesthesia can be tolerated.
Anticoagulation medication is a contraindication that frequently arises during aquablation workup. It is highly recommended that a patient considering aquablation have their urologist, cardiologist, and hematologist collaborate to discuss the safety measures of the operation. The patient can move forward with surgery once a consensus and treatment plan are reached between physicians with stopping and restarting anticoagulation medication. Antiplatelet medication should be stopped a week before surgery, while anticoagulation medication like Xarelto and Eliquis is stopped two or three days prior. Urologists performing aquablation have been successful in managing coagulation and bleeding in the operating room, as only a small percentage of patients have experienced complications.
[Dr. Jose Silva]:
Ali, who would you say is not a candidate for this technology?
[Dr. Kasraeian]:
Honestly, really, the things that you have to think about are people that may not be candidates for surgery and anesthesia and things of that nature. That's one thing that we have to be very mindful of, is the surgical candidacy of this, especially in light of the fact, and this is one thing that we talked to as the emergence of things like prostate artery embolization, which I know is a very controversial topic as we as urologists try to preserve our fields and BPH and things of that nature, so I know that that's a bit of a challenge, but I think if you work well with your interventional radiology colleagues, you can build relationships that matter.
For example, my own retro radiology often sends me patients to go and talk to him and they've never had a workup of their BPH. He'll call me up and say that, "I'm seeing a patient who's interested in BPH, but he's never had a workup. He's here with a catheter and I don't know whether he's in retention because of an atonic bladder or because of BPH." Then you'll meet that patient and they may be disgruntled at the fact that they have to go through a workup, but it's a wonderful relationship that allows for that. The surgical candidacy is an important one.
Then the other thing that you and I have talked about and discussed before that comes up a lot with aquablation, is whether or not people who are previously taking anticoagulation for cardiac issues, the Coumadins, the Xareltos, the Eliquis, even aspirin and Plavix and things of that nature, how do you potentially manage those? The way I manage those is, for people that are on those medications, you want to make sure that you touch base with their cardiologist or the hematologist, the people that have them on those to make sure that it's safe to be off of them and be off of them for the appropriate time period.
With the antiplatelets, I typically want people off of them for about seven days before. For the medicines like the Xarelto and the Eliquis, two to three days before, and then look to appropriately restart them when you feel that you're comfortable to restart them and make sure that patients are doing okay from that standpoint. Fortunately, we've been very blessed that we've been able to do that. We've been able to take care of our patients who are on these medications and get them off safely, get them to those therapies, and get them back on those medicines safely.
We've been very fortunate that we have not had much difficulty in terms of patients going back to the operating room because of bleeding. We have not had a big transfusion rate. We've just finished our five-year experience, where we're about 150-plus patients. I think we just passed 154, 155 patients in our experience. We've had in our experience, I think, three patients who've had transfusions, and two of those patients actually were getting transfused because of bleeding from a very large prostate.
In the process of that evaluation and during the hospitalizations and things of that nature, talking to their cardiologist, because of concurrent medical issues, this seemed to be one of the safer things to do to open up their prostate channels and deal with the bleeding once all that was stabilized and they were doing well from that standpoint. Again, and this was a time where we did not have anyone doing prostate artery embolizations and things of that nature. They actually weren't being transfused specifically because of bleeding associated with the aquablation procedure, which is a current process.
One patient our anesthesiologist just decided to start giving a transfusion, and they had a hemoglobin something around 15 or 16 afterwards. We showed up in the recovery room and he was just hanging blood. I just count those three because, realistically, they got a transfusion, but they probably could have done fine without it. That gentleman could have.
[Dr. Jose Silva]:
Those transfusions were the first patients that you did or?
[Dr. Kasraeian]:
Very early in the experience. All three of those patients were in the first six months to a year of our experience, but really within the first early experiences. Interestingly, so when we were first doing this procedure, very similar to the WATER studies, we weren't doing a bladder neck cautery.
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Pre-Op & Intraoperative Measures for Prostate Aquablation
The pre-op process for aquablation continues to evolve as more research is published regarding the potential benefits of certain aspects of the patient workup. When aquablation first emerged as a BPH treatment, enema was always performed to ensure an evacuated rectum during the operation. Over time, the standard protocol has transitioned to where the enema is no longer mandatory before surgery, and stool-related matters are handled while in the operating room.
Generally, the workup for aquablation consists of performing a cystoscopy, urodynamics test, and volume measurement of the prostate with ultrasound guidance. Prostate biopsy may also be performed if risk factors are present.
A common practice during aquablation is to administer thromboxane, a technique adopted from orthopedics for routine joint procedures. Providing intravenous thromboxane has been shown to decrease the amount of bleeding during surgery. Aside from limiting bleeding, the literature relating to the intraoperative aspects of aquablation has yet to show statistical significance in any actions or alternative techniques for the procedure. Aquablation is still a relatively new treatment for BPH, and future research should guide urologists in providing optimal care for BPH.
[Dr. Jose Silva]:
Ali, in terms of pre-op, anything special with these patients? You've already mentioned anticoagulation. Are you doing any enemas or anything prior?
[Dr. Kasraeian]:
Yes, and it depends. Early on, we were doing enemas on everyone from that standpoint of things, and now typically, we've gotten a little bit away from that aspect of things. Then we assess things in the operating room, and if there's stool, we take care of it from that standpoint of things. Sometimes we talk to patients about their bowel habits and things of that nature and see. Not on a routine basis from that standpoint, and it really hasn't affected our ability to see from that aspect of things. We assess patient comfort, personality, and things of that nature to some degree from that aspect of things.
In terms of the workup, we do a cystoscopy, we do a urodynamics test, we do a volume measurement of the prostate, usually with an ultrasound, and then again, we do all the assessments for prostate cancer risk from that standpoint. Typically, if there's a risk of prostate cancer, we do a biopsy beforehand, especially if they're young. Some of our older patients, they often opt for doing the biopsy concurrent to that, especially if, when we talk to them, they have absolutely no way that they're considering a radical prostatectomy and there's an option that they're going to consider.
We have very frank discussions about that, and that has to be an absolute for them, or else we do the biopsy beforehand, because I don't want to take that off the table for them from that standpoint of things. Those are some of the preoperative workup that we do.
[Dr. Jose Silva]:
Yes, I pretty much do the same, definitely, those patients. I did aquablation on a 92-year-old guy. He had a PSA in 20-something, but he wouldn't change. The guy had a catheter, and he just wanted to continue life without a catheter, so I'm not going to do a biopsy on him. Then intraoperatively, do you do any medications or anything, thromboxane? I have heard some people using thromboxane.
[Dr. Kasraeian]:
It's interesting, early on, we did a lot of research in terms of other things to potentially add to it. I remember all the committees I went to talk about getting thromboxane and TXA and all those type of things accredited for us to use as urologists. For people that may not know, this is something that orthopedic surgeons use very routinely when they do joint procedures and things of that nature to decrease the risk of bleeding from that standpoint. The idea with this, some people with aquablations use it preoperatively, essentially when you're doing the procedures as given IV, and it's been associated for other procedures to lower the risk of bleeding.
For the aquablation data, it's really very mixed. There's really nothing that's been a home-run study that says, "When you use this, it knocks it out of the park." The concern with it is there are theoretical risks of clotting and things of that nature associated with it, but it's not a large risk. The risk is not humongous. For us as pelvic surgeons, we're always concerned with the fact that we're doing prosthetic surgery and pelvic surgery in patients that--
Usually, our patients are older. A lot of our patients have cardiac disease and things of that nature. We're doing a pelvic operation for patients that may not necessarily be the healthiest of patients. Are we going to potentially increase the risk for that? It's just a little bit of a concern of using it. If it's not going to make a big difference, are you going to use it?
For us, when our risk of bleeding stabilized after the bladder neck cautery technique, we abandoned pursuing that because it seemed to be not as much of an issue. When we were pursuing it early in the experience was when we were just going in there and putting the catheter retention device and, it was just a lot more initially stressful of a day and you go home and you're just crossing your fingers of whether you should just stay to the hospital and not come home. Anything to help would have helped. Then, once we started the bladder neck cautery as a routine technique, then it didn't seem like just adding stuff like that made that much of a difference.
Best Practices in Aquablation Post-Op Care
Aquablation post-op care typically includes the placement of a three-way French Foley catheter to resolve any issues of incontinence or retention. Depending on the patient's urethral and meatal caliber, a 22- or 24-size Foley catheter is used after surgery. Smaller sizes, such as 20 or 18 French three-way Foley catheters, are not optimal in many cases as they resemble a true lumen too small for easy irrigation that can cause future problems. For most patients, there is no traction placed on the Foley catheter since the traction can bring the catheter into the prostatic urethra, leading to bladder spasms and overactive bladder symptoms. If Foley catheters are placed in traction, urologists should be mindful of the amount of traction administered. Only a low amount of traction is needed for effectiveness after aquablation cases.
Foley catheters can be left in for patients about five to seven days after their procedure. However, Foley catheters can be removed after a couple of days if the patient responds well to surgery and passes urine without significant issues. BPH patients suffering from urinary retention, larger prostates, and prostates with a median lobe require more attention concerning catheter removal. These patients are more susceptible to experiencing an episode of dysuria after aquablation. Therefore, it is ideal for this subset of patients to not have their catheter removed close to the start of the weekend, as most urological clinics only operate during weekdays if medical attention is needed.
[Dr. Jose Silva]:
Post-op, what Foley do you use? You use a three-way, the patient continues on irrigation?
[Dr. Kasraeian]:
Yes. Basically, I use a 24 French three-way Foley catheter. Interestingly, our hospital as a routine did not have the Royce silicone catheter from that standpoint and it was starting to become, amazingly, a bit of a production to put it in from that standpoint. Finally, we had a few in there and I found that it didn't make that much of a difference in terms of anything. Our patients were a little bit more uncomfortable with pulling it out because there's a little bit of a lip between the balloon and the actual Foley. They were a little bit more uncomfortable when we took it out.
Because it didn't make much of a difference, we have the red, just regular Foley catheter. I may explore getting a silicone catheter, see if that potentially can help from that. We use between a 22 and a 24 French three-way Foley depending on the patient's urethral caliber, and really, the meatal caliber.
[Dr. Jose Silva]:
The miadal, that is the problem here.
[Dr. Kasraeian]:
The meatus is a caliber and it's really something we're paying a lot more attention to because I think that meatal strictures and stenosis are really, in my opinion, just anecdotally looking at it, are related to if someone's meatus is not from a caliber standpoint suited for a 24 French and they'd be better with a smaller catheter. Sometimes that irritation of the catheter being in there could have potentially have an effect. If their urine is relatively clear, we don't necessarily need it, I think the 22 French may work as well.
Those are the sizes that we work with, and it's just, with a concern that if you put a catheter that's a bit too small, like a 20 French or an 18 French three-way, you're actually getting too small of an actual true lumen of the catheter because of that third irrigation port. If you need to start doing irrigations and things like that, you're actually having a smaller working channel from that standpoint. The 22 and the 24 help you from that standpoint.
[Dr. Jose Silva]:
Do you leave them all on traction?
[Dr. Kasraeian]:
Depends. Most people lately, no, because it finds like when you put it on traction, because you leave such a big open channel, the traction brings it into the prosthetic urethra and you cause more problems than you help, either by stirring up a little bit more breathing or more overactive bladder symptoms or bladder spasms.
[Dr. Jose Silva]:
The spasms, yes, definitely.
[Dr. Kasraeian]:
Then if I do put it on attraction, I'm very careful to secure it in place because it's a very subtle amount of traction that you want and you don't want it to pull and jab. When I do it, is I do it when the legs are down, because if you put it in one place where the legs are up in the lithotomy position, when you bring it down, now it's a whole different ball game, from that standpoint.
[Dr. Jose Silva]:
Ali, you mentioned that they stay overnight, one day, the next day they go home. How long are you keeping the Foley?
[Dr. Kasraeian]:
For me, that's always a million-dollar question. About a third, 30% to 40% of my patients travel. I usually do these cases on a Tuesday, and if we have a lot of cases, we add a second, like Wednesday, day. For me, if they go home Wednesday, I see them Thursday or Friday. I am a bit superstitious. I'm a little bit concerned about pulling catheters on Fridays or later in the week because inevitably if something's going to happen, it's Friday night and I don't have any clinics on the weekend and things like that. I tend to leave them in through the weekend and pull them Monday morning. It tends to be five to seven days, but that's really mostly logistical aspect and for people's travel schedules and things like that.
The fact that 50% of our patients are retention patients, so I don't want to pull it on a weekend and then they have an issue. A lot of times for most of our patients, we try to set up home health nursing and things like that. It's not yet been a big issue. We bring them in early in the week, early in the appointments, and we get the catheter out, and that's worked well for them both in terms of travel and also to try to create an uneventful weekend for them from that standpoint.
[Dr. Jose Silva]:
Yes. I do them on a Wednesday, and my first four cases, I removed the Foley on Friday, all of them, and only one passed the avoidant trial. The other still retained some. Now just doing our trial the next Monday, and I haven't had an issue since.
[Dr. Kasraeian]:
Yes. It's really a logistical aspect of things just to make sure that they have an uneventful weekend and let it be-- It really hasn't been an issue. I know some people take the catheter out sooner and people do great with it from that standpoint. For me, it's just when the people that are traveling, the size of the prostates that we typically take care of, most have a median lobe, half of them are in retention. It's just to make sure that they don't have any events over the weekend, because if that happens, they're going to the emergency room.
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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