New procedure treats enlarged prostates with water jets
Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.
Men with enlarged prostates have a variety of treatment options, including medication and surgery. And now a urologist at Upstate is offering one more option. It's called aquablation. And here with me to explain how it works is Dr. Hanan Goldberg. Dr. Goldberg is an assistant professor of urology at Upstate. Welcome back to "The Informed Patient," Dr. Goldberg.
Hanan Goldberg, MD: Thank you. Thanks so much for having me.
Host Amber Smith: So what is aquablation?
Hanan Goldberg, MD: Aquablation is a relatively new procedure and part of the many procedures that are today available for the treatment of what we call BPH or benign prostatic hyperplasia, benign prostatic enlargement, which basically means enlargement of the prostate that happens to all men with age.
As a result of that, men suffer from lower urinary tract symptoms, frequency, urgency, weak stream, trouble emptying their bladder. And that is all mostly because of the prostate being enlarged and obstructing their urethra, obstructing their bladder from emptying completely. And that's one of the procedures that is now available to treat BPH.
BPH procedures are usually divided into resective procedures and nonresective procedures, which means either we cut the tissue, or we do something that pushes the tissue aside. So that is the nonresective tissue. Aquablation is part of the resective tissue because tissue is actually being cut.
What we do in this specific procedure, it's a minimally invasive procedure. There's no incisions. We don't open the abdomen. There's no surgical incisions or anything like that. We go in through the urethra, through the natural orifices, and basically it uses a free water jet controlled by robotic technology to remove prostate tissue and create a channel that men can empty their bladder.
Host Amber Smith: So this is for someone whose prostate has enlarged to the point where they're having symptoms that are making their life difficult.
Hanan Goldberg, MD: Correct.
Host Amber Smith: Is the procedure painful?
Hanan Goldberg, MD: So the procedure is done in the hospital, under general anesthesia. The patient is completely asleep. He doesn't feel anything. He doesn't remember anything. It takes approximately one hour, give or take, and the patient wakes up, once the procedure is done, with a catheter, which is a tube going inside through the urethra, into the bladder and draining his urine. And the reason we put in a catheter is because it allows the urethra and the prostate bed, where the surgery was performed, to heal faster.
Catheter is usually in anywhere between one to three days. And patients usually stay one night in the hospital. And the next morning they go home with, or without, a catheter, depending on the surgeon, depending on the procedure. But the catheter, as I said, usually is removed within one to three days after the procedure.
Host Amber Smith: Now, you were describing how water is used. Does the water push the tissue out of the way, or does it do something to remove the tissue?
Hanan Goldberg, MD: So this is a high water jet that is emanating from a robotic probe that goes inside through. The prostate, and the water actually completely ablates, completely resects, the tissue, and it actually completely makes it disappear. It is all removed completely because the water jet is so strong.
It is actually used in the metal industry to cut metal. So, we of course do this in a very accurate manner. And part of the advantages of this procedure is that we use both a camera that goes in through the urethra that is called a cystoscope, but we also use an ultrasound probe that goes through the rectum during the procedure. So we have two methods to actually view the prostate.
And the way the procedure is done is that we plan, before the actual surgery takes place, during the procedure, there is a planning phase where we actually can pinpoint exactly where we want the robotic arm that has the water jet coming from it, where we want that water jet to hit and what kind of tissue we want to destroy. And that's using the ultrasound that is in place during the procedure.
Host Amber Smith: How new is this procedure? How long has it been FDA approved and in use?
Hanan Goldberg, MD: I think FDA approved it approximately two to three years ago, if I remember correctly.
And there's been some studies done on this, actually many studies, already. When I looked a few days ago, I think more than 140 studies have already been done on aquablation procedure. There's been a randomized, controlled study that has actually compared aquablation to the gold-standard procedure, which is called the TURP, the transurethral resection of prostate, which, that procedure's been around for, I don't know, 50, 60 years, something like that.
That is the gold-standard procedure that we compare it to. That is also a minimally invasive procedure, but it uses electricity to cut tissue. And the randomized study that was done that was comparing aquablation to the TURP procedure was done in men with prostates ranging between 30 to 80 grams, which is the majority of men.
And it was shown that this procedure is as effective as a TURP, if not even more, with less side effects, so that is the great advantage of this procedure.
Host Amber Smith: After the procedure, have you created a new, second channel for urine, or is it the same channel, that you've just replaced the original channel?
Hanan Goldberg, MD: Good question. It's the same channel. It's not a new channel, but basically what happened to the old channel is that prostate tissue has grown, and pretty much obstructed, that channel. And then it's very difficult for the bladder to empty urine. And what we do is, basically, we remove that obstruction in the same channel, allowing the bladder to have the old open channel that it was used to when the man was younger.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith talking with urologist Hanan Goldberg about a procedure called aquablation, for men with enlarged prostates.
What type of patient is the best candidate for this procedure?
Hanan Goldberg, MD: The good thing about this procedure is that, as people might know, we are all different, and we all come in different shapes and sizes, and we all have a different prostate size.
Some of us have small prostates, some of us have very big prostates, and also the shape of the prostate is very different, and that really does affect what kind of surgical intervention and what kind of treatment we can offer men. But one of the many advantages of aquablation is that this is pretty much appropriate and suitable for any kind of prostate, any size, any shape. There's reports of this being done on prostates as small as 30 grams and prostates as big as 300 grams, so that's why any man with any kind of prostate is basically an appropriate candidate for this procedure.
Host Amber Smith: Does it matter if the man had tried medications before the procedure, or if he'd had another procedure before?
Hanan Goldberg, MD: So a lot of the men that we actually see are men that have previously been treated with some sort of modality, whether it's medications, which is probably the most common one, or some kind of previous intervention, and again, aquablation is a suitable treatment for these men. This could be the first treatment that you're receiving. This could be a treatment that you're receiving after you have failed another treatment, such as medications, such as UroLift, such as HoLEP (two other surgical procedures), or any other surgery that is available today for men with BPH.
Host Amber Smith: Are there any conditions that would prevent someone from having this procedure done?
Hanan Goldberg, MD: Men who take anticoagulation medications and have some kind of contraindication and cannot stop it, that is a clear contraindication for this procedure.
Of course, if someone is too sick, and we cannot put him to sleep because we need to use anesthesia for this, of course this is also not something that I would offer that patient, but the percentage of these men is usually very, very small.
Host Amber Smith: You talked about planning that gets done before the procedure. What involves the patient, or is there any testing that the patient would go through?
Hanan Goldberg, MD: No. The planning phase is done while the patient is already asleep. That is actually the part of the procedure that takes the longest, because this is done while the patient is already asleep.
He's lying down, the ultrasound probe is already inside him, in the rectum, and the camera port, the cystoscope, is already inside the urethra. And basically we use the ultrasound to map the prostate exactly where we want the water jet to cut. And that is why it is so accurate, because we can actually control where we cut more, where we cut less, to preserve different organs, different areas that we know are important for later function, whether it's sexual function or whether it's urinary function.
For instance, the bladder neck, which we know that is the area where the prostate connects to the bladder itself, we try to preserve the bladder neck as much as we can, because we know that has a function in incontinence and in controlling your urine and not leaking.
And that is also important for ejaculation, for sexual function. So with the aquablation, we can actually pinpoint, and completely decide, how deep the water jet goes, how strong the water jet is. And that way we can basically do a whole plan of the prostate, and we know exactly what is being cut, how deep and how strong the water jet will be.
Host Amber Smith: What are the potential complications?
Hanan Goldberg, MD: Like any other procedure that is a resective procedure for BPH, we always talk about incontinence, and we always talk about erectile dysfunction, and we always talk about what we call retrograde ejaculation, which basically means that the ejaculate ... it's not that it doesn't exist anymore, but instead of going forward, it actually goes backward -- that's why it's called a retrograde -- goes inside the bladder. And it's diluted in the urine, and then the man just voids (urinates) it out.
So I would say, according to the data that we have, including the randomized studies that were done on aquablation, the erectile dysfunction and incontinence rate are zero, basically. It just doesn't exist. The retrograde ejaculation, I would say anywhere between 15% to 30%, that can happen, which is lower than the TURP procedure, which is, again, the gold standard, which we compare this procedure to, and that is something that we always consult our patients and let them know.
It's important to know that although ejaculation is very important to most men, it has medical significance only if you are trying to bring children. If you are not trying to bring children, this really does not have any kind of effect on the man. And most men that we do this on, as you can imagine, bringing children is not part of their agenda at this point.
But it is important for a lot of men, and we do counsel them that it can happen, and anywhere between 15% to 30%, which is, again, better than most other procedures.
Host Amber Smith: Now, you already said that it usually comes with an overnight hospital stay, and the man wakes up from the procedure with a catheter that may stay in for one to three days. Beyond that, are there any other guidelines that you want to make men aware of for during the recovery?
Hanan Goldberg, MD: Yes. So, it's important to note that the reason we keep them overnight is not because we are doing anything, but what happens is that, as I said, they wake up with a catheter, and they have irrigation to the bladder, which means that there's water flowing in through the catheter and actually coming out through the catheter, and the goal of that water, that irrigation, is basically to clear all pieces that might have been left, to clear any blood, any clots that might have been left. And that allows us to monitor the color of the urine for at least 24 hours after the procedure and make sure that before the patient goes home, his urine is in a satisfactory color, and he's not bleeding.
And that way we know that at least he's been observed for 24 hours, and his urine is getting back to normal color. What happens after we remove the Foley catheter (the urine drainage tube), in terms of recovery, again, like any other resective procedure of the prostate, HoLEP, TURP or other procedures that are done today, the most common symptoms, at least for the first two to three weeks, are a little bit of frequency, urgency, burning. That is all part of the healing process, and that is to be expected in aquablation as well.
Host Amber Smith: How soon after the procedure would a man notice that symptoms of BPH are clearing up?
Hanan Goldberg, MD: Most men notice that the stream is automatically, significantly, improved right after the catheter is removed. They feel that immediately because the channel is so much bigger right now. But again, because of these symptoms that I mentioned before, I think they truly feel the real improvement within two to three weeks, when these symptoms go away and they're not bothered by them anymore, and then they really, really feel how improved their stream is.
What we actually do before the procedure and after the procedure, we have them void, we have them urinate, in a special machine that can actually measure their flow. And then they can see visually, aside from of course feeling it, how improved their stream is. And we have many patients that their flow is actually tripled or even quadrupled, and it's flow. It's much faster now. It's much stronger now. It's a very clear improvement.
Host Amber Smith: For some men, is this a permanent solution?
Hanan Goldberg, MD: So the prostate tissue, unfortunately, grows back, but it does take a very long time.
And with the aquablation, I think, at least, from all the procedures that I know and do, that is the procedure that takes a very significant amount of tissue out. More than the TURP, I would say. And with the amount of tissue that is being removed, the time that it will take the tissue to grow back is many, many years.
So for the majority of men, this will be the first and final procedure, and they will not need any additional procedures after this.
Host Amber Smith: We want to let listeners know they can call the main 315-464-1500 number for the urology department at Upstate to learn more about this procedure or get connected to you.
Hanan Goldberg, MD: Yes, absolutely. Right now the aquablation device is available in our Utica office. I'm hoping it will be available in other offices as well. And it's important to know that in the Upstate area, this is the only place that aquablation can be done right now. The closest place after us is probably New York City. So in the whole entire area of Upstate New York, this is the only place that this can be done.
Host Amber Smith: Well, Dr. Goldberg, thanks for taking time to tell us about it.
Hanan Goldberg, MD: Thank you so much for having me.
Host Amber Smith: My guest has been Dr. Hanan Goldberg. He's an assistant professor of urology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening."