Health Aquablation 

Written by Alix Boyle

Photography by Stan Godlewski

Middlesex Health is now offering Aquablation therapy, a new technique to treat urinary problems that are the result of an enlarged prostate, also known as benign prostatic hyperplasia (BPH). The procedure employs the power of high-velocity water under robotic guidance to cut away problematic prostate tissue. Doctors say it’s so promising, this minimally invasive surgery may replace the transurethral resection of the prostate (TURP) procedure, considered the gold standard of prostate surgery.

Unlike other prostate procedures, Aquablation causes fewer complications such as erectile dysfunction, ejaculatory dysfunction, and incontinence. The procedure is done under general anesthesia and can be used on any size of prostate. 

Around 30 percent of men over 50 have BPH. The prostate sits at the base of the bladder and surrounds the urethra like a donut. When the prostate enlarges, the tissue presses on the urethra, interrupting the flow of urine. The condition can be mild, moderate, or severe and cause problems like a weak urinary stream, irritative frequency of voiding, difficulty urinating, incomplete emptying, and frequent urination, to name a few. Others have severe symptoms that disrupt their sleep and interfere with their quality of life. BPH is a non-cancerous condition. 

Dr. Edward G. Myer, M.D., a board-certified urologist, and urologic surgeon, has practiced urology for 14 years. He completed residencies in both urology and surgery at UConn Health. He recently trained in Aquablation with Dr. Lewis Kriteman, one of the early adopters of the technique.

In a recent interview with Seasons Magazines, he discussed BPH and the new procedure. 

Q. Dr. Myer, can you please 

describe Aquablation?

A. It’s a technique to remove prostate tissue with high-velocity water jets, essentially power washing the tissue away under robotic guidance. First, an ultrasound probe is inserted into the patient’s rectum and locked into place. Then, the cystoscope, or camera, and the Aquablation handpiece are locked together and inserted as one unit into the urethra. The scope and handpiece are guided into the bladder under direct vision through the scope. They are then locked to the ultrasound probe. The end of the Aquablation device is positioned at the bladder neck, and the cystoscope is withdrawn to the apex of the prostate. The contour of the tissue that is to be cut away is mapped out with the ultrasound in three dimensions. The water jet is then activated and follows the marked contour from the bladder neck to the apex of the prostate.

The surgery takes less than an hour; most of the time is preparation and planning. The resection with the water jets takes about four minutes. Other surgeries can take one to two hours.

The water jet was developed in industry to cut glass, stone, and metal. The water comes out almost at the speed of sound.  In medicine, the water jet has also been used to resect liver and bladder tumors, but the greatest application is with the prostate.

Q. Who is a candidate for Aquablation?

A. Any man with a large prostate. An enlarged prostate will squeeze the urethra. Up to 88 percent of men in their 80s will have BPH.

Q. How long have you been offering 

the treatment?

A. I have been doing it since March, and the other urologists I work with at Middlesex Health are going to learn how to perform Aquablation therapy too.

Q. How long does the patient spend in the hospital after Aquablation?

A. Patients are in the hospital just overnight. Some leave the same day.

Q. How many days after the procedure can the patient go back to work and other activities?

A. After Aquablation, the patient has a catheter in his bladder for two to three days and is then seen in the office to take the catheter out. After that, he can get back to driving and work. We advise our patients to avoid strenuous activity and tell them not to lift anything weighing more than 20 pounds for about four weeks. That could cause bleeding until the prostate lining is reestablished.

Q. What are the benefits of Aquablation over other treatments for BPH?

A. Treatments can be medical or surgical. Some men take herbal supplements, which smaller studies show are helpful. Larger studies don’t show much benefit. There are two classes of prescription medications, alpha blockers, such as Flomax, which relaxes the prostate, and 5-alpha reductase inhibitors, such as Proscar, which can shrink the prostate. Medications are only effective up to a point.

Then there’s surgical management. TURP (transurethral resection of the prostate) is the reference standard for prostate surgery. It’s been around since the 1920s. It’s performed by inserting a resectoscope into the urethra and up to the prostate and trimming away the excess prostate tissue that’s impeding the flow of urine.

Nearly 100 percent of men who get TURPs lose ejaculation. One of the biggest advantages of Aquablation is that the majority of men preserve their ejaculation. Aquablation also takes less time in the operating room, and there’s generally less bleeding and fewer days spent in the hospital afterward.

I first encountered Aquablation at a conference in 2018, and initially, I thought it would disappear like many other technologies. Over the years, a lot of technology has come along to reduce the size of the prostate, such as microwave ablation, needle ablation, steam ablation, and stents to hold the prostate open. They’ve come, generated enthusiasm, and then gone away. But after the studies came out showing the effectiveness of Aquablation and after observing the procedure, I was sold. This is a technology that could potentially replace a TURP. It’s reproducible and because it’s done robotically, so it takes surgeon variability out of the equation. There’s no thermal injury, like with a TURP, because room temperature saline is used.

Q. What’s it like to live with BPH?

A. That’s very individual. Some men will seek treatment at the onset of symptoms, and some will live with their symptoms for years. Some men will dribble all day and think it’s the way they have to live for the rest of their life. Some hard indications, like urinary tract infections, urinary retention, someone who can’t pee at all, bladder stones, and kidney failure — all necessitate treatment. They can start with medication, but in these cases, I would recommend surgery sooner rather than later. 

The two most common causes of BPH are age and family history. Men should know they don’t have to live with symptoms; early treatment can lead to better outcomes.

All men should have a yearly prostate screening. If it’s done judiciously, it can find cancer when it’s still curable. 

Visit MiddlesexHealth.org/urology for more information.