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Clinical Focus

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

Jason Hafron, MD; Aaron D. Berger, MD; Arpeet Shah, MD

Medical Crossfire® in Adjunctive Testing: Charting a New Course in Prostate Cancer Risk Assessment

 discusses notable data on the UroLift System for the treatment of patients with benign prostatic hyperplasia (BPH), which were presented at the 2023 American Urological Association Annual Meeting in Chicago, Illinois. Gange is a urologist at Summit Urology Group in Salt Lake City, Utah as well as an Associate Medical Director for Teleflex. He discusses the following abstracts:

MP76-03: "Procedural Complications Associated with MIST and Invasive Surgery Compared to Disease Progression with Medical Therapy"

PD41-06: "Pooled analysis of 330+ subjects treated with the Prostatic Urethral Lift (PUL) reveals undertreatment impacts durability"

MP76-17: "Successful Outcomes in Acute Urinary Retention (AUR) Patients Treated with the Prostatic Urethral Lift (PUL) are Associated with Earlier Intervention"

The data were presented at the recent American Urological Association Annual Meeting. 

Dr. Gange discusses data on the UroLift System for BPH

® Assistant Editor Janelle Hart spoke with 

 He discusses the stigmas associated with enlargement of the prostate, or benign prostatic hyperplasia, and why more education is necessary to absolve these misconceptions. McVary is a professor of urology at the Stritch School of Medicine and director of the Center for Male Health at the Loyola University Medical Center in Maywood, Illinois.

“Even though there [are] many therapies that one can do, it's not a sign of anything ominous for most men,” says Kevin T. McVary, MD, FACS.

Destigmatizing Urology: Dr. McVary discusses enlarged prostates

paper, New Endoscopic In-office Surgical Therapies for Benign Prostatic Hyperplasia: A Systematic Review, for which he served as senior author. Lee is an Associate Professor of Urology and Healthcare Policy & Research at Weill Cornell Medicine Department of Urology in New York City.

The study encompassed the prostatic urethral lift (UroLift), water vapor thermal therapy (Rezum), and temporary implantable nitinol device (iTIND).

Study: New BPH treatments demonstrate efficacy

“While there are other treatment options available for treating BPH, there remains a significant need for much less invasive treatment approaches that can preserve and protect the integrity of the urethra and other critical structures," says Ryan Rhodes. 

Phase 1/2 trial launches of Focal One robotic HIFU for BPH

"Aquablation is versatile. It can manage a very wide range of prostate sizes and shapes," says Stephen Overholser, MD.

Dr. Stephen Overholser shares his experience with Aquablation for BPH

A full market release of the HYDROS System is expected within the current quarter.

FDA grants 510(k) clearance to AI-powered robotic system for Aquablation therapy

The guideline includes 38 recommendations on managing incontinence following treatment for localized prostate cancer or benign prostatic hyperplasia.

AUA, GURS, SUFU amend guideline for incontinence after prostate treatment

The new Category I code will become effective on January 1, 2026.

Aquablation granted new category I CPT code for BPH management

Kevin C. Zorn, MD, FRCSC, FACS, discusses the implications of findings from the study, “An analysis of benign prostatic hyperplasia surgical treatment reimbursement trends across Canada: Examining provincial changes over the recent decade with comparison to cost of living changes."

Kevin Zorn, MD, on the potential impact of inconsistent compensation for BPH surgery

, discusses the implications of findings from the study, “An analysis of benign prostatic hyperplasia surgical treatment reimbursement trends across Canada: Examining provincial changes over the recent decade with comparison to cost of living changes,” for which he served as the senior author. Overall, the study showed variations in the reimbursement for BPH treatments across Canada, as well as rates that failed to keep up with inflation.

Zorn is the founder and director of BPH Canada in Montreal, Canada.

What are the implications of these findings?

Certainly, I think when you have these inherent challenges or biases in the reimbursement aspects, it has to beg the question, does this or how will this impact the future of acquisition or passing down of these newer technologies? Where will they fit? I believe in Manitoba, now in Quebec, they're going to be offering the Rezum MIST procedure using a code with the same reimbursement as a TURP. So, for the same urologist, or different urologist, one's going to go off and do 250 g HoLEP, a 3-hour endeavor, and then someone will go do a 5- or 6-minute Rezum, and they get paid the same reimbursement. It begs the question, will this influence the behaviors of those offering treatments? And will that impact some people to maybe abuse certain things outside of indications and against the global increase of its adoption in practice?

I think there needs to be a pause and reflection, looking at maybe designating—like in diving—degrees of difficulties. You're going to have one that's going to be more challenging than others, or another area of expertise that has to be considered. The implications, I think, that may limit or pose challenge as we introduce more of these MIST technologies—Optilume BPH, iTind, and these other techniques. They're in an orphan state, at least in Canada, not covered by most provincial coverage programs. The question is, how do you fit them in? Do you create a new slot and a new reimbursement appropriate to that and make sure that they're all balanced. What I'm seeing is a bit of an imbalance at present in where we fit this in. "Well, we'll use a TURP code." I guess that's great for the average urologist, but for those 5% of people who are brave and are leaders in advancing BPH in these more challenging, anti-coagulated, larger prostates, it's challenging. There has to be some sort of fight for them to say, "look, this doesn't make sense." The implications, I guess, are challenging as we bring on new technology and making sure that there's a fairness across the urological community in Canada.

What future work is planned based on this study?

With this data and having reached out to the individual 10 province KOLs, there's Dr Connor Forbes, who has done fellowship in HoLEP and a leader in BPH in British Columbia. He and his team have responded saying we should also do this for all therapies, including open, simple prostatectomy and other types of cost analysis and adoption across Canada. I know that they're spawning interests of doing something similar, looking at the data set of numbers of procedures performed, and seeing if some of these factors we talked about have influenced or changed adoption. Where are we at with laser? Where we at with HoLEP? To get some number of users. Is that growing? Is that remain stagnant? And how [are] all these technologies we want to bring to patients to have better outcomes, shorter recovery, longer durability, are they impeded? Because, number 1, access, and 2, interest of the surgeon for the inherent things we just talked about.

This transcript was AI generated and edited by human editors for clarity.

Videos

The study highlights significant disparities in reimbursement for benign prostatic hyperplasia (BPH) treatments across Canada, with rates not keeping pace with inflation. This raises concerns about the adoption and integration of new minimally invasive surgical technologies (MIST) like Rezum MIST, Optilume BPH, and iTind, which are not widely covered by provincial programs. The current reimbursement model may influence treatment choices and potentially lead to misuse. Future work aims to expand the analysis to include other therapies and assess their adoption and impact on patient outcomes.

“Certainly, I think when you have these inherent challenges or biases in the reimbursement aspects, it has to beg the question, does this or how will this impact the future of acquisition or passing down of these newer technologies?” says Kevin C. Zorn, MD, FRCSC, FACS. 

Ravi Munver, MD, gives advice for health care professionals incorporating Aquablation with the HYDROS Robotic System 

Expert gives advice on implementing Aquablation with the HYDROS Robotic System

 gives advice for health care professionals incorporating Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia into their armamentarium. Munver is the vice chair of the department of urology at Hackensack University Medical Center (HUMC), as well as the director of minimally invasive and robotic urologic surgery, the chief of living donor kidney surgery, and the director of the minimally invasive robotic laparoscopic and reconstructive oncology fellowship program at HUMC in New Jersey.

What advice would you give health care professionals just starting to provide Aquablation treatment to patients?

For urologists that are interested in implementing Aquablation into their armamentarium, I am very envious, because anyone who is going to start doing Aquablation now is going to be using the HYDROS System. And the HYDROS System was built on years of research from the first-generation Aquablation system, and now with the advances of the first-assist artificial intelligence technology, the integration of cystoscopic and ultrasonic images combined with the robotic technique and the treatment planning that's created specifically for each individual patient, it makes adoption of this therapy that much easier. I'm not saying that Aquablation was a difficult procedure to learn in the first place. The learning curve is not very steep. However, there are many components that need to be understood. You need to understand about transrectal ultrasonography. You need to understand about treatment planning and angles. You need to understand about how a prostate anatomy is going to impact how you do the actual procedure. And you need to understand what the power levels of the water jet imply at different parts of the prostate. Once you understand these components, the procedure learning curve is really not that steep, but for anyone who is little weary or anxious about learning a new technology, the HYDROS System makes it that much easier, so the adoption is going to be faster. It's going to cut minutes off the procedure. For those of us who have been doing this for a while, but it'll probably cut 10, maybe even 15, minutes off of a procedure for a nonexperienced or someone early in their learning curve. The procedure, in and of itself, for those who have been doing this for a while, is typically under 1 hour. Well, you're already talking about a short procedure duration. And think about it with the HYDROS technology and all of the aspects that are involved, to cut minutes off of a 1-hour procedure, or a 40-minute procedure or a 30-minute procedure, and make it even 5, 10, or 15 minutes shorter, allows the patient to get off of the operating room table faster. It allows a faster recovery, and it allows you to be able to do more surgeries in the same day. So we're offering BPH technology and treatments to more patients.

Aquablation with the HYDROS Robotic System offers significant advancements for treating benign prostatic hyperplasia, integrating artificial intelligence, cystoscopic, and ultrasonic imaging for personalized treatment planning. The learning curve for this procedure is manageable, with essential knowledge in transrectal ultrasonography, treatment planning, and prostate anatomy. The HYDROS System simplifies adoption, reducing procedure time by up to 15 minutes, enhancing patient recovery, and increasing surgical throughput. This efficiency allows healthcare professionals to treat more patients effectively, optimizing the use of operating room resources and improving patient outcomes.

"For urologists that are interested in implementing Aquablation into their armamentarium, I am very envious, because anyone who is going to start doing Aquablation now is going to be using the HYDROS System," says Ravi Munver, MD.

Kevin C. Zorn, MD, FRCSC, FACS, describes the background and notable findings from the study, “An analysis of benign prostatic hyperplasia surgical treatment reimbursement trends across Canada: Examining provincial changes over the recent decade with comparison to cost of living changes,” 

Kevin Zorn, MD, on variation in BPH procedure reimbursement across Canada

, describes the background and notable findings from the study, “An analysis of benign prostatic hyperplasia surgical treatment reimbursement trends across Canada: Examining provincial changes over the recent decade with comparison to cost of living changes,” for which he served as the senior author. Zorn is the founder and director of BPH Canada in Montreal, Canada.

Could you describe the background/rationale for this study?

The rationale for conducting this study was to look at the Canadian experience with TURP and the other surgical therapies like TURP, mainly in 2023. [We] work[ed] with key opinion leaders in every province to get the code. Number 1 is to show people across the world, outside of Canada, that although there is a universal health care principle, each province has its own sovereignty on choosing the code and the reimbursement for every technique. In this case, TURP, the staple BPH procedure done by all urologists––that's our bread and butter. [It] used to be the biggest number in terms of surgical therapies back in the 80s, then medications changed that. But nonetheless, to see how that did in 2023 and then also, compared to [2010], so 13 years have passed. How much change in reimbursement has there been to meet with the cost-of-living index? We wanted to look at that.

Then also, to really team into some of the more advanced techniques, [like] Greenlight for more anti-coagulated patients, it requires more training and little bit longer OR time. And [in] HoLEP, an enucleation technique designated standard of care, especially in larger prostates. We know only about 5% of urologists are offering [this] or have gone to do the necessary extra training as a fellowship to initiate this into their program. Is it equitable compared to some of the other techniques that are there? And to see, is there a designation? That was the purpose of this, to look and show what the differences are in Canada. How do things change over [13] years? And is there a designation and a respect, not an honor, but is there an initial fee for the quality, the skillset, the extra anxiety, the ergonomics, these longer OR times for these more challenging, more difficult procedures. In the States, I think they have different modifiers for those more challenging [procedures]. In this case, HoLEP, anatomic enucleation—I think everyone who's listening will agree that is by far one of the most challenging procedures—is there something specific for that procedure amongst the 10 provinces?

The first would be that amongst the 10 provinces, there's 10 different fees for a TURP. That's remained the same from [2010] to 2023. [There are] some big variances of at least 20%-30% differences between provinces—that's just for TURP. From 2012 to 2023, there's 2 provinces that had the same fee structure for physicians that had not changed. The others were all single digit percentages. Compared to the cost-of-living index, it was far inferior. It did not keep up with the cost-of-living index for the staple urological procedure. I think those are our main findings just for TURP.

[When] we look at Greenlight and anatomic enucleation like HoLEP, there's only 3 of the 10 provinces that had a designated code or a small modifier. In Quebec, they have an additional $100 if you have at least 2 or 2.5 hours of anesthesia time. Otherwise, same code as TURP. I think [that is] the key finding, is that there's a disparity. There's not an increase of reimbursement across all provinces in Canada that met up or was at par with the cost-of-living index. In the States, they have different CPT codes for individual MISTs, TURP, enucleation that have, I think, appropriate RVUs or reimbursement for those levels of challenges that is not being seen in the global components of Canadian health care.

The study examines reimbursement trends for benign prostatic hyperplasia (BPH) surgical treatments across Canadian provinces, focusing on the period from 2010 to 2023. Despite a universal healthcare system, significant provincial disparities exist in reimbursement rates for transurethral resection of the prostate (TURP) and advanced techniques like Greenlight and HoLEP. The findings reveal that reimbursement rates have not kept pace with the cost-of-living index, with only a few provinces offering additional compensation for more complex procedures. This highlights the need for equitable reimbursement structures across Canada.

“There's not an increase of reimbursement across all provinces in Canada that met up or was at par with the cost-of-living index,” says Kevin C. Zorn, MD, FRCSC, FACS. 

Raevti Bole, MD, discusses the role of lifestyle modifications in the management of benign prostatic hyperplasia 

Raevti Bole, MD, on the role of lifestyle modifications in managing BPH

 discusses the role of lifestyle modifications in the management of benign prostatic hyperplasia (BPH). At the 2024 Sexual Medicine Society of North America Fall Scientific Meeting, Bole presented the talk “Updates in Nonsurgical BPH Management.” She is a urologist at Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio.  

What role do lifestyle modifications play in the management of BPH, and how do you integrate these approaches into your treatment plans?

This is really interesting. Over a third of Americans actually use some kind of what we term complementary or alternative medicine approach. And I think it's just people wanting to get healthy and integrate lifestyle changes into traditional medicine. A lot of these treatments have been studied, from things like yoga and hypnosis and exercise and stress reduction, and then nutraceuticals, so plant supplements. I will say the research is very interesting. It's difficult to interpret, just because there's such wide variability in all of these things. If you're doing yoga, what kind of regimen are you on? How long are you doing it? If you do hypnosis, what kind of hypnotic suggestions are you being exposed to? If you are taking a plant supplement, what is it? What's the dosage, what's the purity, what's the variation between the batches that you might pick up at a store? And so all of these things make it very difficult for your doctor to just sit down and tell you, "Take this or do yoga and your symptoms will get better." It's really not ever as clear as that, but I think there's a lot of promise in making certain lifestyle changes and just being up to date with the literature, and knowing what helps, what doesn't help but may not hurt. And overall, I think the focus on stress reduction, being active, eating healthy. In many cases, there are some data to support having more of a plant-based diet. I think all these things show the interest of all of our communities in trying to integrate not just drugs and surgeries but also their overall health and well being.

Lifestyle modifications play a significant role in managing benign prostatic hyperplasia (BPH), with many Americans incorporating complementary or alternative medicine approaches. These include yoga, hypnosis, exercise, stress reduction, and nutraceuticals. However, the variability in these treatments makes it challenging for physicians to provide specific recommendations. Despite this, there is promise in lifestyle changes, particularly stress reduction, physical activity, and a plant-based diet. These approaches reflect a broader interest in integrating overall health and well-being with traditional medical treatments for BPH.

"Over a third of Americans actually use some kind of what we term complementary or alternative medicine approach," says Raevti Bole, MD.  

Raevti Bole, MD, discusses patient characteristics she considers when weighing nonsurgical treatments for benign prostatic hyperplasia 

Nonsurgical BPH treatments: What are key patient characteristics to consider?

 discusses patient characteristics she considers when weighing nonsurgical treatments for benign prostatic hyperplasia (BPH). At the 2024 Sexual Medicine Society of North America Fall Scientific Meeting, Bole presented the talk “Updates in Nonsurgical BPH Management.” She is a urologist at Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio.

How do you assess the long-term durability of nonsurgical treatments for BPH?

That's a good question. I think the main point here is that they're not meant to be durable. All the nonsurgical treatments that we're talking about in the review we just gave at the SMSNA are medical options. [These] are things that you have to continue doing every day. And for some people, that's something that really works for them. They don't mind taking a medication every day because [there's] the feeling that it's temporary and they can stop at any time if they want to. That's something that they want. Durability is something that's important to folks who say, "I just want to be 1 and done. I want something that's definitive. I want this to last a long time and not have to take something every day."

Are there specific patient characteristics or factors that may influence the likelihood of treatment success and the need for alternative treatments?

Yes, absolutely. So whenever someone comes into my office with urine trouble, and says, "What do you recommend?" and they're trying to go with something a little less procedural and maybe something more like what we're talking about, something nonsurgical, I tell them, "I don't want to have to worry about you hurting your body on whatever treatment that you're on." I want to make sure that they're a good candidate in the sense that they don't have some kind of kidney damage that's going to put them at risk for further kidney damage if the treatment is not as strong or aggressive as it needs to be. I want to make sure that I know how strong their bladder function is, because bladder damage can sometimes raise the risk that one of the less procedural or definitive treatments might work well for you over time. I want to make sure that the treatment is working, so once I put someone on a medication, if they had any problems with emptying their bladder before, or any problems with urinary infections or blood in the urine, I need that to clear up for them, or else that's not going to be a viable long-term treatment option for them that's actually going to benefit in the long run.

Dr. Raevti Bole emphasizes that nonsurgical treatments for benign prostatic hyperplasia (BPH) are not designed for long-term durability, as they require daily administration. Patient preferences for temporary versus definitive solutions play a crucial role in treatment decisions. Key patient characteristics influencing treatment success include kidney health and bladder function. Ensuring that nonsurgical treatments effectively address symptoms like bladder emptying, urinary infections, or hematuria is essential for their viability as long-term options. Patient safety and treatment efficacy are prioritized in selecting appropriate management strategies.

Raevti Bole, MD, recently presented a talk at the SMSNA Fall Scientific Meeting on nonsurgical BPH management.

Ravi Munver, MD, discusses the furure potential of Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia

Expert discusses AI and Aquablation for treating BPH

 discusses the furure potential of Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia. Munver is the vice chair of the department of urology at Hackensack University Medical Center (HUMC), as well as the director of minimally invasive and robotic urologic surgery, the chief of living donor kidney surgery, and the director of the minimally invasive robotic laparoscopic and reconstructive oncology fellowship program at HUMC in New Jersey.

How might Aquablation evolve in the coming years?

Where can Aquablation go in the coming years? I think artificial intelligence is really in its infancy right now. The term is used on a daily basis. We are surrounded by artificial intelligence, but really we are in its infancy. Artificial intelligence involves machine learning. It involves deep learning and the integration of neural networks. Aquablation with artificial intelligence is only as good as the data that's inputted. Where we are right now with artificial intelligence is we're at that machine learning phase. [This is] machine learning based on inputted data from thousands of prostate sizes and shapes, so that the technology can identify the specific landmarks within a prostate. The next generation may involve deep learning. The deep learning is the ability to learn from the mistakes or from prior procedures and make adjustments. As the Aquablation procedure is being performed with the HYDROS system, while the treatment planning is done with artificial intelligence, the actual treatment with the robotic water jet is being performed, but the surgeon himself or herself is actually monitoring that treatment to make any minor adjustments. What I mean by that is that if the water jet is too powerful in 1 area or not as powerful in another area, minor adjustments with the press of a button, a plus button or a minus button, can adjust the power of the water jet. But the treatment plan itself has already been preprogrammed.

Where Aquablation with the HYDROS system is also really, really innovative, is that you can actually see the treatment plan before the procedure starts, and that indicates that the channel that you create through the prostate is illustrated in an animation so you can decide if you like that treatment path, so that when the procedure is done, you will see what the channel looks like before it was even created. Other therapies, you're actually seeing the channel that's created as you're doing it, but you're only seeing it from the inside, because the prostate is like a donut or a tunnel. So you're inside the tunnel, and you're making the tunnel wider, but you don't know how much room you have to make that tunnel even wider. With Aquablation, because of the real-time ultrasound image and the 3D animation that's created, you can see the actual dimensions and shape of the tunnel that's created before you even start the procedure. That is absolutely incredible.

Aquablation, utilizing the HYDROS Robotic System, is poised for significant advancements in benign prostatic hyperplasia treatment. Currently, artificial intelligence (AI) in Aquablation is at the machine learning stage, using data from numerous prostate sizes to identify landmarks. Future developments may incorporate deep learning, allowing the system to learn from past procedures and adjust accordingly. The HYDROS system's innovation lies in its ability to visualize the treatment plan pre-procedure, offering a 3D animation of the prostate channel, enhancing precision and predictability in surgical outcomes.

"With Aquablation, because of the real-time ultrasound image and the 3D animation that's created, you can see the actual dimensions and shape of the tunnel that's created before you even start the procedure," says Ravi Munver, MD.

Ravi Munver, MD, discusses the versatility of Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia

Ravi Munver, MD, discusses the versatility of Aquablation treatment for BPH

 discusses the versatility of Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia. Munver is the vice chair of the department of urology at Hackensack University Medical Center (HUMC), as well as the director of minimally invasive and robotic urologic surgery, the chief of living donor kidney surgery, and the director of the minimally invasive robotic laparoscopic and reconstructive oncology fellowship program at HUMC in New Jersey.

What factors do you consider when determining whether a patient is a good candidate for treatment with Aquablation?

When I think about the ideal candidate for Aquablation, this is a 1-stop-shop, and what I mean by that is it's a one-size-fits-all. Aquablation can be used for small, medium, large, and extra-large prostates. Prostates come in all shapes and sizes, and most other resective therapies and non-resective therapies for BPH are limited by size, shape, or variations in anatomy. Aquablation has no limitations, so any prostate, any size or shape, can be treated with [it].

There are a couple of contraindications, and 1 of the main contraindications is a patient that's on blood thinners. If someone is actively on blood thinners and cannot stop the blood thinners for an operation, that is a risk for bleeding, just as it would be for many of the other resective therapies. In those instances, there are options that are available for the patient. A second potential contraindication for Aquablation is for someone who doesn't have a rectum, or if they don't have the ability to place an ultrasound probe in the rectum, because this is ultrasound guidance, and it's done through a transrectal ultrasound probe. Those are the 2 main contraindications. But I'll tell you, in my years of doing Aquablation, I've never come across someone without a rectum, and I've never had to really talk about many patients who have been on active anticoagulation who could not at least stop the therapy for a couple of days before the operation and then resume the therapy shortly thereafter.

Aquablation with the HYDROS Robotic System is a versatile treatment for benign prostatic hyperplasia, accommodating prostates of all sizes and shapes. It is a one-size-fits-all approach, unlike other therapies limited by anatomical variations. However, contraindications include patients on blood thinners who cannot pause their medication and those without a rectum, as the procedure requires transrectal ultrasound guidance. Despite these limitations, such cases are rare, and most patients can temporarily stop anticoagulation therapy to undergo the procedure safely.

"Aquablation can be used for small, medium, large, and extra-large prostates," says Ravi Munver, MD.

 discusses the real-time, ultrasound-guided technology that is part of Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia. Munver is the vice chair of the department of urology at Hackensack University Medical Center (HUMC), as well as the director of minimally invasive and robotic urologic surgery, the chief of living donor kidney surgery, and the director of the minimally invasive robotic laparoscopic and reconstructive oncology fellowship program at HUMC in New Jersey.

Can you explain how HYDROS' real-time, ultrasound-guided technology allows for a personalized treatment plan for each patient?

Aquablation is like no other transurethral therapy that has come about in the last 100 years. The TURP procedure is still the gold standard. It's a resective procedure that removes tissue using a lot of cautery. A lot of side effects are associated with this procedure, but it's still the gold standard, and the number 1 procedure that's performed in the United States. Aquablation is revolutionary. With the HYDROS system, it offers artificial intelligence-powered technology to allow the prostate margins, size, and shape to be identified so that a treatment plan can be individualized for the patient. It uses real-time ultrasound imaging. No other BPH therapy uses real-time ultrasound imaging to not only plan for the prostate tissue removal, but also for use during intra-operative removal of the prostate tissue. So you can see what's happening in real time. Number 3, it's heat free, so there's no thermal energy that's used during the removal of the prostate tissue, which means that there are fewer side effects and fewer irritative symptoms after the procedure - irritative symptoms that include frequency, urgency, burning, and just pain from the procedure. And lastly, there is real-time ultrasound imaging that's integrated into digital cystoscopy. That's a novel aspect comparing the first generation and second generation Aquablation system. HYDROS incorporated enhanced imaging with digital cystoscopy as well as improved ultrasound imaging for the prostate, so it allows us to do a better operation and be able to see much more clearly. To answer your question, the real-time ultrasound imaging with the artificial intelligence-powered planning, called FirstAssist AI, and enhanced imaging quality, heat-free water jet resection, not mentioned is that this is a robotic procedure. What that means is that once the treatment plan is created, the robotic technology removes the prostate tissue under real-time ultrasound guidance, without the surgeon needing to make manipulations with his or her hands, so that it allows standardization of the procedure, something that's never been encountered with any transurethral BPH therapy over the last century.

Aquablation with the HYDROS Robotic System represents a significant advancement in the treatment of benign prostatic hyperplasia (BPH). Unlike traditional TURP procedures, Aquablation utilizes real-time ultrasound imaging and artificial intelligence to create personalized treatment plans, enhancing precision and reducing side effects. The procedure is heat-free, minimizing irritative symptoms post-operation. The integration of digital cystoscopy and improved ultrasound imaging further refines the process. The robotic nature of the procedure standardizes treatment, eliminating the need for manual surgical manipulation and offering a novel approach to BPH therapy.

"Aquablation is like no other transurethral therapy that has come about in the last 100 years," says Ravi Munver, MD.

BPH treatment system includes real-time, ultrasound-guided technology

Marcelino E. Rivera, MD, highlights potential future advancements in the areas of stone disease and benign prostatic hyperplasia 

Marcelino Rivera, MD, on potential future advancements in stone disease, BPH

, shares what he envisions for the future of stone disease and benign prostatic hyperplasia (BPH). Rivera is an associate professor of urology at Indiana University School of Medicine and the director of the endourology fellowship at Indiana University Health in Indianapolis.

For stone disease and stone removal, we're really seeing the use of steerable suction catheter, steerable suction scopes, making surgery much safer and much more efficient. I just mentioned the MONARCH trial; we got a miniPCNL that has the ability to remove large amounts of stone through suction steerable catheters. There's a new scope, the CVAC, or the Calyxo scope, that has the ability to do suction ureteroscopy. There's also a handful of suction steerable ureteral access sheaths out there as well. So, we have all of this new technology that’s about a year old, making surgery a lot safer for patients, making things more efficient, and [giving us] the ability to see stone removal happening from a perspective where we can visualize stone clearance in a way that we haven't been able to before.

When we look at the BPH arm, or the HoLEP arm of the change in technology, when it comes to BPH, there's always going to be a lot of different technology out there. One of my partners does Aquablation, we're looking into other technologies, like Optilume, trying to get those on board as well. It's very important to have an armamentarium that you're offering your patients. We'll always have that in BPH. But I think the important thing is "let's make sure we're doing the right procedure for the right patient." And also, if we have people who want to learn how to do enucleation, what do we have to educate and to teach them how to do these procedures? I think the future is really bright from an educational perspective on the HoLEP or enucleation arm, training people with different modalities. Instead of using patients right away, do we have certain models that are very facile and that work really well? And then do we have a curriculum in place that can do that? I think with the study of our residents, getting an idea of what they find as difficult for an enucleation procedure, we can really focus on the more challenging parts of the procedure, perhaps teach them outside the patient, and then start to utilize that curriculum and advance and make their learning career much less. That's the bright side of the BPH or enucleation technology.

This transcription has been edited for clarity.

Advancements in stone disease and BPH treatment are being driven by new technologies, such as steerable suction catheters and scopes, which enhance surgical safety and efficiency. The MONARCH trial and innovations like the CVAC scope are pivotal in improving stone removal. In BPH management, diverse technologies, including Aquablation and Optilume, are expanding treatment options. Emphasis is placed on matching procedures to patient needs and enhancing education for enucleation techniques. Developing effective training models and curricula is crucial for improving procedural proficiency and reducing learning curves.

“So, we have all of this new technology that's about a year old, making surgery a lot safer for patients, making things more efficient, and [giving us] the ability to see stone removal happening from a perspective where we can visualize stone clearance in a way that we haven't been able to before,” says Marcelino E. Rivera, MD. 

Ravi Munver, MD, gives an overview of Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia

Ravi Munver, MD, discusses Aquablation with the HYDROS Robotic System

 gives an overview of Aquablation with the HYDROS Robotic System for the treatment of benign prostatic hyperplasia. Munver is the vice chair of the department of urology at Hackensack University Medical Center (HUMC), as well as the director of minimally invasive and robotic urologic surgery, the chief of living donor kidney surgery, and the director of the minimally invasive robotic laparoscopic and reconstructive oncology fellowship program at HUMC in New Jersey.

Please provide an overview of Aquablation with HYDROS.

Aquablation is a transurethral water jet, resective, ablative procedure for men with BPH or benign prostatic hyperplasia, also known as an enlarged prostate. Of all the BPH therapies out there, there are non-resective therapies and there are resective therapies. The non-resective therapies do not remove any prostate tissue and are focused on quality of life. The resective therapies remove prostate tissue, but actually have some side effects that can compromise quality of life. Quality of life after a BPH procedure involves urinary continence, erectile function, and sexual function. Aquablation with the HYDROS system is the next generation of Aqubalation therapy. The HYDROS system offers a number of benefits over the first-generation Aquablation system. These benefits include artificial intelligence-powered treatment planning, which allows for personalized treatment planning for any type of prostate, [regardless of its] size, shape, or anatomy. Second, it involves real-time ultrasound imaging. So not only do we use ultrasound imaging for pre treatment planning, but we also use ultrasound imaging during the procedure. This is the only transurethral BPH therapy that uses image guidance, and the real-time ultrasonography allows us to really create an individualized treatment plan. Third, there is enhanced digital cystoscopic imaging. It uses the digital cystoscope that's integrated into the ultrasound so it saves time, and it allows you to see both ultrasonic and cystoscopic images on the same screen. Finally, it's heat-free water jet resection with robotic technology. There's no thermal energy that's used during the actual removal of the prostate tissue, and the robotic technology allows the water jet to remove the tissue without the surgeon having to control the water jet with his or her hands, because the treatment plan has already been created. All these aspects allow for a fast procedure, enhanced pre-planning, digital and ultrasonic imaging, and improved quality of life afterwards. So what Aquablation offers is that there's no incontinence, there's no erectile dysfunction, and minimal sexual dysfunction. It's the only therapy that offers the benefits of a true resective therapy, which is what it is, as well as a non-resective therapy.

Aquablation with the HYDROS Robotic System is an advanced transurethral water jet procedure for treating benign prostatic hyperplasia (BPH). It combines resective and non-resective therapy benefits, enhancing quality of life by avoiding incontinence and sexual dysfunction. The HYDROS system features AI-powered treatment planning, real-time ultrasound imaging, and digital cystoscopic imaging, allowing for personalized, heat-free, and efficient prostate tissue removal. The robotic technology eliminates the need for manual control, ensuring precise and individualized treatment, ultimately improving patient outcomes and minimizing side effects.

"[Aquablation] is the only therapy that offers the benefits of a true resective therapy, which is what it is, as well as a non-resective therapy," says Ravi Munver, MD.

Benign Prostatic Hyperplasia

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