Feasibility of Aquablation prostate surgery performed as day cases

Abstract

Lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) affect approximately one third of men aged >50 years in Europe [1]. About 30% of patients will require surgical intervention due to worsening LUTS or complications from BPE or failure/non-compliance of medical therapy. TURP has been the ‘reference’ standard for surgical treatment of BPE. However, in the last two decades the landscape for surgical BPH treatment has exploded to include numerous surgical techniques largely divided into minimally invasive surgical treatment (minimally invasive surgical therapy—Urolift, Rezum, temporary implantable nitinol device) or cavitating prostate surgeries (holmium laser enucleation of the prostate, photoselective vaporisation of the prostate, thulium laser enucleation of prostate, Aquablation). Despite all these options, the in-patient load for healthcare systems for BPE surgery remains large and as outlined in the ‘Getting It Right First Time’ (GIRFT) practical guide to improving the management of BOO (January 2022), there is encouragement to explore ways of delivering a greater percentage of day case procedures, in order to alleviate that burden. Aquablation of the prostate is an image-guided, robotically delivered procedure employing a high-velocity waterjet to ablate and remove tissue. Aquablation is performed using the AquaBeam System (PROCEPT BioRobotics Inc., Redwood Shores, CA, USA) and has recently received the ‘standard’ recommendation from the National Institute for Health and Care Excellence (NICE) Interventional Procedure Committee. The last few years has seen a rapid adoption around the world of this technique and following the NICE Interventional Procedures Guidance (IPG), this likely to be true in the UK. The standard approach is to plan for a 1 or 2 night in-patient stay prior to catheter removal. However, with pressures of inpatient hospital beds and refinement and adoption of a standardised technique for haemostasis combined with dedicated postoperative recovery review and follow-up, we have taken an approach of delivering Aquablation on a planned day case basis on selected patients. We outline our early experience to enhance the facilitation of such an approach to the wider urological community. Since the introduction of Aquablation in 2015, numerous clinical trials have shown Aquablation to be an effective, safe treatment of men with LUTS due to BPE leading to sustained improvement in LUTS, whilst maintaining sexual preservation. The WATER trial (ClinicalTrials.gov number: NCT2505919) was a prospective international multicentre trial randomising Aquablation to TURP (prostate volumes 30–80 mL) reporting non-inferior symptom relief compared to TURP and a lower risk of sexual dysfunction, with superior safety and efficacy for 50–80 mL prostates [2]. The WATERII trial (NCT03123250) then addressed the larger prostate glands (80–150 mL) and showed it to be similarly effective and safe [3]. A meta-analysis and systematic review of Aquablation, which included seven studies (n = 551 patients), reported that IPSS improvements and maximal flow rates were reproducible and sustained at 12 months, whilst relatively preserving sexual function [4]. More recently, the 5 year outcomes of the WATER and WATERII trials have confirmed long-term efficacy across the range of prostate volumes [5]. In our institution, patients with LUTS are seen in a dedicated one-stop male LUTS clinic. If a patient chooses to undergo Aquablation, selected patients (living within 30 miles distance, responsible adult will be at home) will be earmarked and booked as a day case, and therefore told about the same day discharge with catheter and a return to our dedicated trial without catheter (TWOC) clinic run by a specialist nurse 3 days later. We perform Aquablation under general anaesthesia with antibiotics and tranexamic acid at induction. Patients are placed in the lithotomy position and the linear transrectal ultrasound probe (