Dr. Stephen Overholser shares his experience with Aquablation for BPH

Stephen Overholser, MD

In this interview, Stephen Overholser, MD, discusses benign prostatic hyperplasia (BPH) treatments he offers, outlines the learning curve and patient selection process for Aquablation, and shares why it’s important for patients to discuss supplement use with their physician. Dr. Overholser is a urologist with Minnesota Urology.

Could you provide an overview of the different BPH procedures that you routinely perform in patients?

I try to have something to offer for every shape and size of the prostate. I will do UroLift and Rezum in the office. I still offer the conventional bipolar TURP, which remains a versatile and reliable procedure. I also do Aquablation. The use of Aquablation in my practice is expanding. And then there are certain situations where a more invasive approach, like robotic simple prostatectomy, is helpful [and] useful. And I offer that as well. And so I do try to solve every BPH presentation with a unique solution tailored to the anatomy and the patient's predicament and complaints.

How long have you been performing Aquablation?

I've been doing it for a year here [in Minnesota]. It was FDA approved in the United States in 2018, and I've been doing it since 2019. I was an early adopter. I did my first case in North Carolina in 2019, and really, the volume has taken off from there.

What was the learning curve like for Aquablation?

The learning curve for Aquablation is pretty flat. The technology definitely helps you grasp it faster. Generally, all urologists have the knowledge and skill to do a TURP, and therefore having those additional layers of technology to ablate the tissue, treat it-- it only helps that procedure to be more precise. The pre-existing knowledge that a urologist has that they bring with them to Aquablation only helps them learn it that much faster.

My experience, starting in 2019, to the present, has been a lot of fun, actually, as we've, over the years, fine-tuned the technique and the approach for Aquablation. PROCEPT BioRobotics has been very receptive to the clinical users on the ground, really, from the beginning. They took what they learned in WATER II, which was their trial to get approval, and we've added a substantial amount of knowledge on top of that study. The current iteration of the procedure as it stands today, throughout the United States and Europe and elsewhere, doesn't look much like the one that rolled out in 2018, and so it is fun to see that as our knowledge base has grown as users around the world, the procedure is even better [and] safer than it was 6 years ago. [I would say it has] a flat learning curve, but with plenty of room to grow and shape your practice.

What is patient selection like for Aquablation?

Aquablation is versatile. It can manage a very wide range of prostate sizes and shapes. That is one of the ways, honestly, I think it got to the market and made an impact so quickly, even despite COVID-19, as an elective procedure. It was able to grow during that period, and that's because of the versatility. It can treat medium and large prostate sizes with a very high degree of effectiveness.

It does, though, have limitations. The prostate cannot be so small that the jet can't pick up a certain amount of force. If we have to turn the jet strength down due to the limited size of the prostate, that can impair the jet's ability to treat tissue effectively.

And of course, there are prostate sizes that would be too big for Aquablation. Those of us who push the envelope with Aquablation technology love to have the biggest size prostate in mind that we've treated, and we wear that like a badge of honor. But truth be told, there are prostates that are too big and there are prostates that are too small, and having someone who is experienced in understanding what the technology can and can't do really sets patients up for success if they choose Aquablation.

What advice would you give other providers that that are looking to bring on Aqualation as a service line in their practice?

[I would say] Go for it. One of the benefits of Aquablation would be for the user who doesn't have an answer for all the different prostate sizes. For example, if somebody has a larger-than-average prostate, some urologists in certain hospital venues might shy away from attempting to treat that prostate with a conventional TURP or some of the office-based solutions that they might have at their disposal. Aquablation really does allow you to expand your treatment range. Of course, there are limitations, and each urologist has to be comfortable with the limitations that their environment has dealt them, but I would say, to anyone looking to get into Aquablation, there is a role for it in everyone's practice, and some urologists might find it really solves a key problem for them with a certain prostate size and shape.

Is there anything regarding Aquablation or BPH in general that you would like to add?

Over the last year of rolling out a new program at a new place, the Aquablation learning curve is very reasonable for a urologist to undertake, but the challenge is getting your perioperative staff, your nursing staff on the floor, all of the support teams that help you get a patient from point A to point B, they do also need to know what's going on with the procedure. They need to have slight adjustments in how they manage catheters after the procedure, the postoperative care that's delivered is very similar in many ways to other BPH procedures, but I have found there are tricks you learn along the way to make the recovery process that much smoother for the patients. Those are the tidbits of knowledge that really separate the new Aquablation user from the experienced one. It isn't the technical skill in the procedure. It's buttoning up those issues in the postoperative period. Experienced users for Aquablation are sprinkled about the United States. There are more and more of them coming online, ready to share that knowledge, and having access to that when rolling out the Aquablation program for a new urologist would be important.

What is a treatment, drug, or tool that your patients are most frequently misusing for their care, and could you provide a brief guidance on how to fix that use?

This is a great question. In the urology space, the answer, relative to my patient care, are supplements. Men and women, but [particularly] men, look at the supplement space as a way to turn back the clock, sometimes even attempt to cure disease. The supplement industry as a whole is hungry for the aging male urology patient. My patients are targets, and so I find that a lot of men misunderstand what supplements can and cannot do.

The issue with relying on supplement use without the guidance of a physician is that you might be mismanaging a diagnosis that maybe is unknown or misunderstood. We're learning more and more say, for example, with BPH, that early intervention is probably one of the best ways to preserve bladder function and to encourage what I call "aging gracefully." Well, if you mismanage the condition early on with a supplement, it could delay your access and progression to appropriate treatment, which could ultimately lead to a different outcome. The supplement industry is trying to sell their goods. I think men relative to the urology space (and women too) need to involve their primary care providers and involve their urologists in the supplement decisions they're making. Many of us are suspicious of supplements, but I think patients would be surprised at how fair and considerate we will be when being asked about the supplements that they're taking. At the very least, it gets you in the door talking about your health, and that's always a good thing.

What would you say is the most important question that you field from your patients? What is your answer to that question?

The most important question, I think, is when patients ask me, "What can I do to help with this condition?" For example, if someone gets diagnosed with prostate cancer, or someone gets diagnosed with a kidney stone, or somebody gets diagnosed with a bladder condition, I am excited when patients ask me what they can do. That tells me already that they're going to be motivated and they're going to participate in their care, which is so important.

Sometimes, the answer to that question is evidence-based and easy. Relative to kidney stones, we have clear guidelines based on the stone type: Here's what you can do to prevent them. When it comes to prostate cancer [and] prostate issues in general, we have some vague ideas about what they can do with nutrition and diet and exercise to help, but those answers are less clear. Generally speaking, what's good for the heart is good for the urinary tract, and so a lot of my answers will, at times, surprise them or be a boring letdown for them, because it's the things that they've been hearing about for the past 10 to 15 years already, which are eating right, getting out, moving. It doesn't have to be a marathon. Just get out and walk, and have more things on your plate that were grown in the ground and [not from a] vending machine. These things are all good for the urinary tract.