Dr. Kevin Zorn on initial Aquablation cases done in an ASC setting

In this video, Kevin C. Zorn, MD, FRCSC, FACS, discusses key takeaways from the study, “Safety and Efficacy of Same Day Discharge for Men Undergoing Contemporary Robotic-assisted Aquablation Prostate Surgery in an Ambulatory Surgery Center Setting-First Global Experience,” for which he served as the lead author. Zorn is the founder and director of BPH Canada in Montreal, Canada.

Video Transcript:

Having done this prospective case volume, which we've done now well [with] over 100 [cases,] but the initial 60 cases to which we had the opportunity to present at EAU and AUA [demonstrated] the fact that these can be done. It can be done safely. We were doing between 4 and 5 cases, starting at 7am trying to be done by 1-2 in the afternoon, thereby giving the necessary time in in the recovery room for the next 4-6 hours. We have a protocol running CBI, getting 5 grades of hematuria color, so that there's a standardization of the hematuria discussion, a certain number of CC's in the balloon, the type of Foley catheter, the administration of lasix and hydration, all the little elements, and medication controlled bladder spasms. It's all the minutia in that sequence and time.

What we found is that there's 1 patient who did have to spend the night because we started him in later in the afternoon, at 3 o'clock, for issues of time and anesthesia. When you do bookcases, you start with the biggest case in the morning. You don't do your 150 grams at 3 o'clock. That was the 1 patient that stayed the night. That was why 98% can be done. So, I think it's a team approach, not just can it be done; you need the right team, the right nurses, and have the whole setup structure, and it can be done. The evolution is continuing, now with a decade of human use of Aquablation, we can now take this to a same-day procedure––discharge the same calendar day.

If I could add to that, I think what we learned, and the devil in the details, is aside from doing your cases, from largest to smallest, patient education, explaining to them that this is going to be done. We would tend to do your standard 2 or maybe 3 pass Aquablation, each being about 5 minutes each. Then using a bipolar loop, I tend to use the thicker loop, resecting the anterior fluffy tissue circumferentially at the bladder neck, really trying to take a lot more of the anterior tissue, which is what a lot of enucleators say about Aquablation is you don't treat the anterior tissue. Well, you're right. There's no beam that goes past 225 degrees, so you're missing some of that anterior Mohawk, like hanging down that could lead to obstruction. But more importantly, it's hard to fit a circular, 60 CC balloon in a space that's not circular. That was the key that we learned. So, aside from doing the Aquablation, can it be done, but using the loop to get rid of that anterior tissue, filling a circular cylinder in a circular peg, when you're a kid, you want to fit that in the right space.

So, once you've done that resection, then we would call it the circle of hemostasis. I go around the bladder neck, making sure there's nothing arterial, especially at the 5 and 7 o'clock locations. Then I do the, I call it the Zorn Zamboni, we just survey, go across back and forth [on the] bladder neck, shut the water off by half, look for significant bleeders, almost like fishermen. Be patient. That's another part that, compared to some of the OR times, we may have spent another 15 more minutes, we resected more tissue. Then I would be very meticulous to make sure there's nothing arterial or venous. So, when you shut the water off at the end of the case, I did that twice. By doing that protocol, then inserting a 24 french hematuria rouge catheter, very stiff, big hole at the end, and I would inflate 10 to 20 CC's in the bladder, then pull that balloon into the fossa, and then blow the remaining 60 Cs so it'd be a total of 60 CC's of balloon to anchor the catheter in its position. Which makes sense, if you have ever had a bloody nose, you pinch your nose. Seems to do the trick. Same thing here, the balloon expands radially and compresses on the border of our surgical site, and that's what we would keep inflated the next 3 to 6 days, depending on the date of surgery. So, maybe we keep the catheter longer as well. Everyone wants their catheter [out] earlier, but having it a little bit longer, I think, adds to hemostasis and also allows that urine to bypass the surgical site. Once the catheter comes out, these patients will have some FUN––frequency, urgency, nocturia––dysuria, so it can mitigate that by leaving the catheter bit longer as part of the patient experience journey, which is now what we're trying to work on.

This transcription has been edited for clarity.