Dr. Sterling and Dr. Friel describe initial experience, patient selection for Aquablation for BPH

"You're not learning much of anything that's new; it's just doing it in a sequence of steps that you haven't done it in previously," says Brian Friel, MD.

In this interview, Matthew E. Sterling, MD, and Brian Friel, MD, discuss the Aquablation procedure for the treatment of benign prostatic hyperplasia, including how the procedure works, what patient selection is like, and what advice they would give other providers just starting out with Aquablation. Sterling and Friel are urologists with MidLantic Urology.

Could you provide an overview of the Aquablation procedure?

Sterling: Essentially, I try to describe it almost like an image-guided TURP, in a way. We use ultrasound for real-time imaging, and the scope utilizes a robotic arm to ablate prostate tissue with a really powerful water jet. Everyone understands a TURP, and so I try to describe it as image guided, so we're telling the robot exactly where to ablate tissue. It's not using any heat, which again, is different than a TURP. And then the robotic arm vaporizes basically what we tell it to vaporize. And so I try to explain it that way. It seems to make sense. I do have to use pictures, because it can get a little confusing with all the different options, but that's kind of how I describe it.

Friel: I agree, and I think people will resonate with doing something under imaging guidance vs I often explain that TURP, which I use in the correct patient, but the limitation of that is you're shaving out prostate tissue in a layer at a time, and you stop when you think you're deep enough, whereas with an Aquablation, you map all that out ahead of time. You know exactly how deep you're going to go, what tissue is going to be resected, and also, probably equally as important, what tissue is going to be spared. That's where the differences, as far as outcomes, I think, is important.

What have the first few months of offering Aquablation been like for you? What was the learning curve like?

Sterling: This is actually in the operating room, so not in the office. I would say Dr. Friel and I did this together the first few months, which was helpful for both of us. We do have assistance from reps from the company. I tell patients this—nothing that we're doing as urologist is a new technique. The ultrasound is not new; we know how to do ultrasounds. The scoping is not new; we do scopes all the time. The new part is basically using the imaging and the software to guide the scope where to operate. From a learning curve standpoint, there's not much to learn. It tends to be fairly quick in terms of your ability to do the procedure. Now, I think with time, there are going to be some nuances that we'll pick up, for sure. But the learning curve is fairly quick; you can pick this up pretty easily vs some of the other prostate procedures that can take a little bit more time to learn how to use it. My patients so far, I would say, have had similar postops to a TURP, maybe a little bit better for some, but others, I'd say fairly similar. I think it's too soon for me to give a definitive idea of how it's going to be but I imagine the postop is going to be fairly similar to a TURP, maybe slightly better for some patients, but it also could be slightly worse for other patients, depending on the amount of inflammation.

Friel: I agree. The learning curve is interesting, because Dr. Sterling said it perfectly. You're not learning much of anything that's new; it's just doing it in a sequence of steps that you haven't done it in previously. I felt that the reps were very helpful, and I agree with Dr. Sterling that doing it together was also very helpful so that we could just bounce things off each other. We did a lot of preparation ahead of time, making sure that we understood how the technology works, A. for explaining to patients, but B. so that when the first day that we were doing Aquablations came about, we were very comfortable with the steps; it was not something that we're trying to recall how to hook up the arms and do all of these things. We knew the set-up, we knew the sequence of events. And so with that all in place, the learning curve is actually quite minimal. It's different than a lot of other procedures where, if you didn't do them in residency, you may not be overly comfortable learning them in practice. This is different than that, because these are all skills that you already have. And so whether or not you've ever seen it before, it's easy to implement in practice. I agree it's a little early to say what the difference will be or similarities between my TURP patients and Aquablation patients. The one thing I'm very interested to see and track going forward is ejaculatory function, because that tends to be what most of the patients that come to me ask about. If they've already learned about it previously, they ask about it for 2 reasons, 1 being they just like the idea that there's image guidance to this and it's more precise, and number 2, they like the idea that there's an increased chance of preserving ejaculatory function much more so at least as far as the data is concerned than in TURP. But I can't tell you that I've seen that yet because it's a little early. Most of my patients I've seen for more of a either 2-week or 1-month postoperative follow-up and they seem to be following the trajectory of TURPs. And we all know TURPs work well for voiding; that's why it's been around for a long time. And so I certainly expect from a voiding standpoint, this is going to give us similar results.

What is patient selection like for Aquablation?

Friel: Some of it actually is self-selecting because people are hearing about it more and come in asking about it first. I do the same work-up in everyone. Everyone gets a cystoscopy to rule out other causes of low urinary symptoms and also so that you have a good understanding of what their anatomy looks like. With different people, there are different considerations. The other important thing, obviously, is prostate size. This varies very much practitioner to practitioner; we've been doing more somewhere between 50-g and 100-g prostates thus far. I know some people go much higher with their volume. We haven't done that yet. But those are the 2 main things, at least from my work-up standpoint, that I want to know: what their urethra looks like, what their bladder looks like, what their prostate looks like, what their prostate size is. And then obviously, what their symptoms are, to make sure that correlates with a need for it. Now, as far as counseling patients, that part is sometimes difficult, because they'll ask what's the difference, from a voiding standpoint, between a TURP and Aquablation, and there's not a lot. And so a lot of my conversation focuses on a couple of things. Some people like that it's a newer technology with image guidance, like we talked about. A lot of people focus on the ejaculatory function, which studies show 8% to 10% have retrograde ejaculation, much lower than a TURP. Like I said, I haven't proved that yet in my own data. And then the other consideration is bleeding, because there tends to be a little bit more blood in the urine after the procedure. If it's someone that's older, that's on blood thinners, things of that nature, those patients I may gear toward something like a TURP that has more cautery involved. We have all the options and try to make it a shared decision and not just me telling them, "This is right" or "that's right" and help guide them.

Sterling: Mine is the exact same. I do the same work-up for everyone. I do a scope, I do an ultrasound. I usually do urodynamics on everyone I'm going to operate on—not always, but I'd say more than 80% to 90% of the time. I do UroLift, I do Rezum, I do TURP, and I do Aquablation. If they fit within the criteria for any of them, I have a sheet that I go through with them. I talk about all their options. I talk about the risks and benefits of each. I think Dr. Friel hit it on the head; for larger prostates more than 50 g, Aquablation studies have shown it to be better than TURP. And certainly it is going to be better than some of the minimally invasive procedures, but everyone's different. Some patients will say, "I understand my urination symptoms might not be better, but I want a quicker recovery. And I want maybe a little bit lower risk." And so Rezum or UroLift might be a better option for those patients. I have other patients that say "I'd rather have something that's going to give me the best chance to void more normally." In larger prostates, definitely, I think, Aquablation is better. A lot of men want to maintain their sexual health, and that's not just erections; that includes ejaculation. When I talk about that, that's a big thing that I've noticed patients really want to maintain. The image guidance is big for patients too, that you're being more exact with things. TURP gets a really bad rap for some reason. Honestly, a lot of patients come in and say, "I absolutely don't want a TURP, but I'm okay with Aquablation." I try to tell them, "The outcomes are pretty similar," but I'm sure if you go on Reddit, Google, and forums, probably everyone that's had leakage or problems with a TURP [talks about it]. Now, TURPs are definitely more variable; every surgeon is different. Whereas I think Aquablation, you're going to find over time, it's going to end up more uniform, because you're using image guidance, you're using a robot to resect in a certain way. In that sense, again, from the learning curve, and from the uniformity, I think it's probably going to be better for the population of urologists. There are urologists that do really good TURPs, where Aquablation will be just the same, and there are some urologists do pretty bad TURPs, and then everyone gets a bad rap about a TURP, and then they come in and they already don't want that. Dr. Friel and I are not really pushy people. We kind of let the patient guide us where they want to go. The vast majority of patients that are having these surgeries are elective for just symptom bother. And so I let them guide me regarding what risks they're willing to take. Now, some patients, it's not purely just for symptoms and there are medical reasons; those are different stories. I'll push them a little bit more than they should have something done. But ultimately, they get to decide.

Friel: I totally agree. I try to be pretty transparent with people about recovery because I have had a lot of patients similar to Dr. Sterling that come in and say "I never want a TURP because my father had a TURP and it seemed like the worst thing of all time." Now, they also had a TURP 30 years ago without a camera and monopolar that they tried to do as fast as they can. And that is a different TURP. I don't paint it all with rainbows. I give them an honest opinion on both sides because I want to make sure they're as comfortable with the decision as I am. Ultimately, that's going to give you your best patient results.

What advice would you give other providers looking to incorporate Aquablation into their practice?

Sterling: I think it's important that they go visit someone that does them. Go to the operating room, see it in person. We both went to a simulation lab, so I think that's also important because you're going to get an expert that's going to talk to you about it, you're going to get hands on before you actually start doing it. You can go through things with people that do them. And if you're lucky enough to be in a place with other urologists, I would try to do it with someone. I think Brian and my's experience is probably unique in most places. But there are a lot of parts of the country where there's a lot of urologists. So I think if you could figure out a way to have multiple people do them, you get the advantage of doing more together at the start, so your learning curve is a little shorter. It's good to be able to bounce ideas off of each other for new things. That being said, the company has been very supportive. And so if we wanted to talk to experts at night and have a conference call, we've been able to do that. Just make sure you're trained and you're prepared for it. But that's anything with surgery.

Is there anything you would like to add?

Friel: I'll say one thing, and I think Matt would probably echo this as well is that, we haven't necessarily, because we're newer to this and we're trying to make sure we're really selecting the correct patients that we're comfortable with doing, we've kind of tapped our volumes. But there are plenty of urologists who will do an Aquablation on much larger prostates that typically weren't an option, really, for a TURP. That's something for the future that we'll see, but it is a nice potential additive to the Aquablation sphere that was just not really a great option previously.

Sterling: I have a few coming up that are larger for sure. For TURP, my cut-off is like 80 or 90 grams for a traditional TURP, and then I'll send it to my partner to do a robotic surgery. But you always get a bunch of patients in that like 90 to 100 gram -120 gram window that previously I was having them go for robotic surgery, and now you can argue no incisions, I can do an Aquablation and get good results. And so, again, I think we'll see what the real-world data shows in a few years but the data that are out there is really good and encouraging. So that's why we picked up on this and wanted to do more of them.

This transcription was edited for clarity.