Aquablation is a minimally invasive surgical treatment for benign prostatic hyperplasia (BPH), or an enlarged prostate. It represents a significant advancement in BPH treatment. In this video, Dr. Bruce R. Kava, professor of urology, director of men’s health at the Desai Sethi Urology Institute, a part of the University of Miami Health System and president of the American Society for Men’s Health demonstrates how this innovative technique offers a precise, effective, and patient-friendly alternative to traditional surgical approaches.
This procedure utilizes a robotically controlled, high-pressure water jet to precisely remove obstructing prostate tissue, guided by real-time ultrasound imaging. The combination of robotics and imaging enhances accuracy, reduces operative time, and helps preserve urinary and sexual function.
Hello, my name is Bruce Cava, and I'm the director of men's Health at the Desiha Urology Institute at the University of Miami Miller School of Medicine. I thank you all for joining us as we discuss one of the late latest advances in the surgical treatment of BPH aquablation. As men age, the vast majority of them will experience a number of voiding symptoms associated with benign enlargement of the prostate. This includes a reduction in the force of strain, sensation of incomplete voiding, hesitancy, and intermittency. In other cases, storage symptoms predominate, which include urinary frequency and urgency, and in some cases urgent continence. Other men suffer primarily from waking up multiple times during the course of the evening, which sleep deprives them. These symptoms are called lower urinary tract symptoms and are often associated with benign prostate enlargement or BPH. In two of the most widely cited epidemiologic studies, from Olmstead County and Boston, the overall prevalence of these lower urinary tract symptoms significantly increased with age, and for men over 50 years old, close to 30% of them had symptoms of moderate, at least moderate severity. Moreover, the economic burden of BPH is tremendous. It accounts for over 8 million outpatient visits to physicians annually in the United States. It significantly impacts the quality of life of these patients and carries a price tag of more than $1.1 billion in direct medical costs. Medical therapy has proved to be highly effective and is often the first line therapy for bothersome lower urinary tract symptoms that are associated with BPH. Data suggest that up to 40% of patients presenting for the first time with, with symptoms suggesting BPH are prescribed one or more pharmaceuticals, and these include uh either alpha agonists, uh, alpha adrenal receptor antagonists, anticholinergic agents, or phosphodiesterase inhibitors. Studies have shown that up to 30% of the men, however, will ultimately discontinue medical therapy, either as a result of of bothersome adverse side effects or lack of perceived benefits. Now 30 years ago, we only had one size approach to to managing patients with lower urinary tract symptoms associated with BPH. This procedure was called a transurethral resection of the prostate. With the patient under general anesthesia telescope was placed into the prostate and using electrical current, the prostate tissue is resected from inside out. I look at, look at it similar to looking in the middle of an, of an orange, resecting that tissue, the meaty portion of the orange, working your way out to the shell itself, and that shell would be considered the prosthetic capsule. Now the TTERP really still remains the gold standard of surgery for BPH because it's so successful at removing the obstructing tissue. Unfortunately, for a small percentage of patients, there are some side effects. In some cases, these include bleeding, infections, and clearly some sexual side effects such as loss of erections and loss of ejaculatory function. Aquaablation is a novel technique that uses high-speed, heat-free saline instead of electrical current to ablate the obstructing prosthetic tissue. This avoids the injury to the, to the tissue around the, the prostate itself, which may occur as a result of the electrical conductivity. And this, that electrical current is thought to contribute to some of the erectile dysfunction and clearly to the ejaculatory dysfunction. So by using a high-speed heat-free saline to ablate the tissue, you avoid that whole situation altogether. The system is designed to deliver minimally invasive therapy, which improves lower urinary tract symptoms. It integrates robotics, direct vision, and ultrasound guidance, and it offers several advantage advantages such as a shorter resection time, predictability, and a reduced likelihood of an ejaculation. As you'll see in our, our presentation, the surgeon will place an ultrasound transducer. Into, into the patient to assess the prostate size and, and the location of the prostate. And then we place our handpiece inside the urethra. Now, this is the biggest difference between the aquablation and the TURP. And you'll see it in our presentation, how this is done. And the reason why this is so important is that during a transurethral resection of the prostate, looking inside the middle of the orange as I, as I spoke earlier, you can't, uh, you can't find where the end of the, the capsule is until you wind up on it. And so that it's very difficult to, to judge that distance. With the ultrasound transducer and the hand piece together, we can judge the distance of the prostate and see how deep we have to resect. This uh this allows us to do a more precise resection. A better resection. And as a result of this, we get, we, we expect that we'll have better overall results. So, I'd like to now present our, our case presentation and um and we'll, we'll talk, we'll come back together to talk about some of these things afterwards. Today we'll be operating on an 80 year old gentleman who's extremely active. Um, he's had lower urinary tract symptoms consisting of frequency, urgency, and a diminished force of stream for some time now. He's gone through a variety of different medical therapies without any effect at all, and he would really like to go ahead and and relieve some of the obstruction so he can live his life with a better quality of life. So. Um, we're positioning the patient right now. He's been put to sleep already, so he's under general anesthesia. Um, the whole procedure should take about 1 hour and a half to do. The actual procedure itself takes about 5 minutes with the water jet, but a lot of the things that we're gonna be doing in the operating room are setting up, aligning the the water jet and allowing the contouring of the prostate using the, the, the robotic, uh, system. So the patient's been positioned in a position called the lithotomy position. His legs are up in stirrups. He's well padded, so it's gonna be very comfortable when he wakes up. It shouldn't really hurt, um, and actually that's the amazing thing about this procedure too. There's absolutely no pain after the procedure when people wake up, they, they often will say to me, did the procedure, did, did you do the procedure already, which is very interesting. So one of the amazing things about this procedure is that we use ultrasound to monitor the progress of the procedure. Um, traditional surgeries involving the prostate involve going inside the middle of the prostate and the urologist really has no control of the depth. They have no understanding of how deep the prostate is based upon the upon the uh the from the from the inside of the prostate using ultrasound though, we can monitor the depth of the penetration through the prostate as we're progressing with the procedure. So we're gonna be placing an ultrasound in the, um, underneath the prostate in order to visualize it better. OK, so basically what I'm doing now is I'm contouring the prostate. In two views, we're using a sagittal view, which is a side view of the prostate to see how, how far it goes into the bladder. Then we use the, the axial view to see how, how the prostate is aligned. So this is a robotic hand piece here. It's connected to a camera so we can visualize the inside of the prostate, and this has the there's a water jet attached to this. This is all robotically driven there's a computer simulation simulator right here which actually allows us to simulate the the the uh size of the prostate and where the where the the various landmarks in the prostate are and this water jet then we once we've contoured it with our ultrasound and aligned everything, we'll be able to tell how. Where the prostate begins, where it ends, and the lateral borders of the prostate itself again, this is the robotic hand piece. This is gonna go on the inside of the prostate and we have the ultrasound monitoring the outside of the prostate so we could really tell the depth of the resection with this. So I'm, I'm positioning my robotic hand piece right now, which is an endoscopic approach. This is the urethra. That's the bulbar urethra and this is finally the prostate where we're approaching right now. And that's he's got a very big median lobe here, middle lobe. And I'm right now I'm in the middle of the urinary bladder. I just get a little bit better focus here. And I'm just aligning our water jet with our ultrasound probe. And I'm looking at the side view of the prostate right now and it looks pretty good, pretty good. I'm, I'm in the bladder with the, with the telescope. I can see the side view of the prostate. I can see the depth that I'll need to go. And then we're gonna pull it back and align my, my water jet now. OK I'm gonna slide this back now. I'm going into the prostate again and you could see where the. These are the lateral lobes and there's a median lobe there. This is what's called the vera montanum here. And beyond that is the urinary sphincter. So his prostate's fairly short. We're gonna park it right here. I'm gonna stop my water. You know, let's move back our our water jet. Perfect. Now I'm gonna see where the, where the water jet is going to be shooting out and and the the actual angle. I'm gonna be pushing on the water jet here. That's perfect. The lineman that's about 9 o'clock. And 3 o'clock. It's good. I'm gonna pull back to the. Mid portion of the prostate now, the widest portion. toggle a little bit here. I think we're very good. This is a this is a nice process to do. Let's uh, let's pull it up a little bit, yeah. The prostate is not as big as as most of the ones that we're doing, which is fine. We're just now contouring the sides of the process of the water jet where we're where the water jet is gonna shoot out to. I think that's perfect. Can, can we move a little bit more lateral on that 3? Can we get a little more, yeah, a little deeper, a little bit perfect. I think that's perfect. Now we're controlling the angle of the actual water jet. And most of the stuff that we're doing during the procedure, the whole procedure takes about 5 minutes or under 5 minutes. Most of the stuff that we're doing is really contouring the prostate, aligning the the water jet with the prostate, and just making sure everything is in good position. So now we're gonna program the computer where the various portions of the prostate are. We're gonna tell the computer that here's the the the middle lobe of the prostate, here's the bladder neck, here's the mid portion of the prostate, and here's the apex. That's the mid middle lobe of the prostate. Our bladder neck is a little bit further back. The mid portion of the prostate is further back beyond that, and then there's our apex. For many men, ejaculatory function is important. That's one of the differentiating factors between this technology and the TURP. TURP 80 to 90% of men lose their ejaculation afterwards. With this, we can program this to do a very precise resection around the ejaculator ducts with cold water rather than with electrical current. And so it preserves the ejaculator ducts very well and it preserves ejaculation in up to 85% to 90% of men. So basically we just aligned everything we programmed it, we told the computer where everything was situated and now it's, now it's just time to do the surgery, which will be about 2 minutes and 16 seconds based upon. The estimate We're gonna go ahead now. That's the water jet you can hear. Hitting the prostate At the top of the at the very base of the prostate, there's not a lot of power because it's being very careful around where the bladder and the and the prostate are are um in a position with each other. And as it goes further into the prostate, we'll see the, the level of the power go up. This is very similar to what a power hose would do in hitting again. I didn't realize until I started doing some research into this that people are using um water jets now to cut aluminum and steel. Uh, it's it's so precise and it does very little collateral damage to the tissue around the actual site that you're actually focusing on. We're about midway through the prostate now through the through the first pass. You can already see from the sagittal view that the prostate is actually has a has an indentation or a little cave in in it where the water jet has already acted on it. As it works further towards the tip of the prostate or the apex of the prostate, now it's going through a butterfly resection, so it's resecting the lateral portions of the tissue rather than focusing on the bottom of the tissue, which is where the ejaculatory ducts are. So it's trying to preserve those ejaculatory ducts. So it went on one side now and now it's going on the other side. So a first pass through the prostate is now complete. We're going to refocus our, our alignment and, and look at everything at this point just to see how well the, the prostate was resected. Usually we run through two passes through the prostate in order to really accomplish. a maximal resection. This lap up a little bit. Perfect. And then we're gonna go through our 2nd pass now. OK recontour this uh on on site if I need to and when it first started, I, I was a little concerned it was going a little bit too deep so I actually readjusted it now by with the hand piece here. The interesting thing about this is really the precision, we're really we've contoured exactly what we want around the prostate capsule to avoid injury to the deeper structures but also to be able to maximally resect the tissue here. Looking in traditionally with the telescope alone without the ultrasound really doesn't give you that depth perception. So. Then move it back, yeah. Yeah We can go in a little bit more, huh? I don't think we need it. open. Yeah. All right. All right. So we finished this portion of the procedure and I'll go in and take a look. With a resectoscope. Cauterize any of the blood vessels that might be bleeding a little bit. I'm gonna go in now with a telescope with this traditional cystoscope. This is the prostate after the. Procedure has been done. This is the, the viewer Montana. This is that that landmark that we used to show delineate the bottom of the prostate, and that's all completely preserved. They did a beautiful job of preserving this lateral tissue here as we go inside the prostate itself. This is, this is virtually resected down to the, the capsule here. What I'm gonna do is I'm just gonna clean up a little bit, a few of the areas here. Especially interiorly with the with the aqua ablation doesn't really address. Because it seems that there's no support anymore for the process of the prostate kind of falls down. And so we're just we're shaving down some of these areas up on the top. And this tissue all fell down because we resected the whole bottom of the prostate. So this is the top of the process that just fell down into the into the view and so now we're just resecting this down. The speed of which we did this is just incredible and we're basically done right now just cleaning up some of the. From the little blood vessels that were opened up partially by me and partially by the unit. It's really incredible though, how, how complete this resection is. And basically basically this patient has this big wide open channel now to urinate through which she didn't have before. And basically what we're seeing here, this is the capsule of the prostate. surgical capsule, so it's really. Wide open, took out the whole middle portion of the prostate there. I'm just gonna take out my chips, the prostate chips. He the back here. Again, it's remarkable how you can look into the bladder, see everything in the bladder here. After the procedure, usually after the transurethral resection of the prostate alone, it's really hard to see because the, the blood. Very little bleeding here. I don't resect a lot of that because again it could interfere with the ejaculatory ducts and. With the erectile function, sculpting a little bit more here off the top just to make it sure he's got a wide open passage anteriorly. Someone tend to hide this gentleman, you can see the all these um what we call trabeculations, little diverticula. This is a sign of of long standing obstruction of the of the bladder. That's what happens to the bladder itself it can deteriorate. Little stone there. Look at this. This is again bladder stones occur in some individuals with long standing obstruction too. They can be a source of infections. OK. So I'd like to thank you for, for joining us during our case presentation today. Um, I just wanted to go over a couple of things before we, we closed. Um, again, BPH is highly prevalent in the adult male population. Most men will go on to medical therapy if they, if they're seen by a physician, and again, 8 million physician visits a year. It's just staggering, with a price tag of over $1.1 billion. So, as, as men go to their doctor, that many of them will be placed on medical therapy as, as a first line of treatment. Unfortunately, 30 to 35% of these men will, uh, the, the medical therapy will be either ineffective, not tolerated well, or actually it doesn't, it doesn't, uh, doesn't do the job for the long term. So surgical therapy is still a very important part of our armamentarium for BPH treatment. Traditionally, we relied on transurethral resection of the prostate. We have a whole variety of other techniques that are available now to, to, um to battle uh BPH and, and to manage it with surgical therapy. But aqua ablation seems to be one of the, the techniques that, that over the course of the course of the last several years has really evolved into, into a major player in this area. The um aquablation offers multiple advantages over the transurethral section of the prostate. And in particular, it offers a reduction in the risk of ejaculatory dysfunction and erectile dysfunction. It's an extremely precise technique. And as we saw in the case presentation, it's, it's very easily performed within a short period of time in the operating room setting. Patients recover rather quickly. They're sent home with a catheter for a couple of days afterwards, but the, the actual, um, the overall experiences has been extremely positive. We Performed over 130 of these procedures at the University of Miami Miller School of Medicine over the last year, and we've had a lot of experience with this and, and I think that our results are absolutely fantastic. Men are, are really, they're voiding very well after the procedure. Very few have actually had experienced any significant side effects. Incontinence is almost unheard of, erectile dysfunction unheard of. A jao dysfunction does occur in about 10 to 10 to 20% of the time. But again, I think that we have a, a fantastic new procedure and we're really excited about, uh, seeing you and, and considering aquablation in the future.
