In this episode, we discuss Aquablation, a new treatment for the urinary symptoms experienced by men due to an enlarged or obstructing prostate(BPH). In previous episodes, we have covered a variety of other BPH treatments ranging from the historical gold standard (TURP) to minimally invasive surgical therapies (MIST) such as Rezum, Urolift, and iTind to more specialized treatments such as HoLEP and robotic simple prostatectomy. So how does Aquablation fit into this spectrum of BPH treatments? How is the procedure performed? What are the risks and benefits? What is the recovery like? And, of course, how effective is it? To help us answer these questions, we are joined by a true expert.
Dr. Joel Hillelsohn
Dr. Joel Hillelsohn is a Clinical Assistant Professor in the Department of Urology at the Grossman School of Medicine at New York University. Dr. Hillelsohn earned his medical degree from the Albert Einstein College of Medicine and then completed his residency training in Urology at the Westchester Medical Center and a fellowship in sexual medicine and reconstructive Urology at Mount Sinai Hospital.
The conversation has been edited for clarity and grammar with the assistance of AI while preserving the original language as much as possible.
Better Man Clinics: Most men are familiar with transurethral resection of the prostate (TURP) or “roto-rooter” in which you core out the inner part of the prostate to allow men to urinate better. How does Aquablation work, and how is it different from traditional procedures?
Dr. Joel Hillelsohn: In traditional procedures, like TURP, you are carving out the inner part of the prostate little by little but you never really know when you are reaching the end or the outside. Aquablation eliminates the guesswork involved in traditional procedures. Using ultrasound, we visualize the end of the prostate so that we do not need to dig in there blindly. You know how far you need to go and program the machine which acts like a powerful power washer that is guided by ultrasound. This precision allows for better and longer-lasting results compared to traditional methods.
Better Man Clinics: Is there human intervention in the actual cutting process, or is it more automated like robotic procedures?
Dr. Joel Hillelsohn: I like to call Aquablation a robotic-assisted procedure. A surgeon guides the process based on ultrasound, using pedals and buttons to control the machine. Towards the end of the procedure, we also ensure everything looks perfect and make any necessary adjustments. It combines the benefits of automation with the surgeon’s expertise.
Better Man Clinics: Is Aquablation considered a minimally invasive or MIST procedure?
Dr. Joel Hillelsohn: Yes, it is. Aquablation is done through the urethra, avoiding surgical scars or incisions. It’s a minimally invasive treatment, but it requires hospitalization for monitoring post-procedure, unlike other same-day outpatient procedures.
Better Man Clinics: Understanding that surgeries are tailored to candidates, what size of the prostate is ideal for Aquablation?
Dr. Joel Hillelsohn: Aquablation is exciting because it’s nearly size-independent. I had a patient who had a 220 gram prostate. A few weeks after his Aquablation procedure I performed a cystoscopy to take a look at his prostate. I looked inside, and it was like, if someone had dug a straight hole in the middle. It was a perfect circle through which to urinate. So, even for larger prostates, it can create a perfect lane for urination.
Better Man Clinics: What about for smaller prostates? Is there a size restriction for prostates that are too small for Aquablation?
Dr. Joel Hillelsohn:
In my mind, as well as for other surgeons performing Aquablation, the lower size cutoff is a prostate that is 50-65 grams. For patients with prostates smaller than that, I tell my patients that they are probably better off either doing a bipolar TURP or, if they are concerned about retrograde ejaculation, a GreenLight procedure. So, for those smaller prostates, I do not believe that Aquablation offers them a significant greater advantage over the other surgical options because of the increased risk of bleeding with an Aquablation versus something like a GreenLight laser, a UroLift or Rezum
Better Man Clinics: Are there any other aspects of the anatomy of the prostate that affect eligibility for the Aquablation procedure?
Dr. Joel Hillelsohn: There are certain shapes of the prostate that make an Aquablation procedure less optimal. An example of this is when you have a significant amount of apical tissue. When you are learning to look at the prostate, its like looking straight down a highway. There are two road barriers called the the lateral lobes which can kind of “squeeze” you in and create a nice little roadblock. There could also be a speed bump, called the median lobe at the bladder neck. Prostates with significant amounts of apical tissue are not ideal for Aquablation. If there’s a very significant median lobe, what I do is that I’ll often do a TURP of the median lobe first. I do this because, if you think of a power washer, there has to be a surface that has to give back tension against it for it to work. The median lobe does not do this. It just hangs there so the water will just kind of bounce off of it rather than eliminating it. So, I tend to eliminate the median lobe first with a TURP in the beginning and then proceed with the Aqublation. That way, the whole procedure would go smoother.
Better Man Clinics: Are there any absolute contraindications to Aquablation, such as blood thinners?
Dr. Joel Hillelsohn: Patients on blood thinners like Coumadin or Xarelto might not be suitable for Aquablation due to the risk of bleeding. In such cases, a tailored approach combining different procedures may be considered.
Better Man Clinics: If a patient is on BPH medications like Flomax, can they stop taking them after Aquablation?
Dr. Joel Hillelsohn: After Aquablation, I usually advise patients to continue alpha blockers for about a week to manage post-operative inflammation and bladder irritation. However, in the long term, the goal is to reduce reliance on medications.
Better Man Clinics: Regarding sexual function, does Aquablation preserve ejaculation compared to other procedures that might cause retrograde ejaculation?
Dr. Joel Hillelsohn: Aquablation spares some tissue related to ejaculation, allowing for potential preservation of ejaculation. During the procedure, there is actually a zone seen on the ultrasound called like a yellow zone which corresponds to tissue important for ejaculation. If a patient is concerned about retrograde ejaculation, you can leave more of this tissue. If they are less concerned, you take more tissue. Aquablation has low risk of retrograde ejaculation. The risk of retrograde ejaculation has about 1% to 3% In my experience.
Better Man Clinics: Guys often equate the risk of erectile dysfunction from radical prostatectomy (used to treat prostate cancer) with that from BPH procedures like Aquablation. Is there a risk of erectile dysfunction or impotence after Aquablation?
Joel Hillelsohn, MD: There is no risk from the procedure itself. However, whenever there are changes in your body, there’s a psychological aspect that can lead to psychogenic ED. It hasn’t happened in my experience, but it’s a possibility with any BPH procedure. Your penis is involved, and anxiety over hearing about side effects of radical prostatectomy and stories of erectile issues after other prostate procedures can trigger the release of epinephrine, the stress hormone. To simplify, when nervous, the body releases epinephrine (adrenaline) which constricts muscles, allowing an outer vein on the penis to open up, leading to potential erection problems. It’s not from the surgery itself but from the anxiety. This is crucial because it’s common for patients to read about the side effects of radical prostatectomy for prostate cancer (rather than procedures for BPH), and worry about erections and incontinence. However, that’s not a real risk with this procedure. Aquablation is meant to improve your quality of life, not treat cancer. We aim to remove the excess benign tissue that obstructs urination, not cancer-causing tissue outside the prostate.
Better Man Clinics: Got it. And you mentioned incontinence or urine leakage. Is incontinence not a significant risk after Aquablation?
Joel Hillelsohn, MD: In the “water trial”, they reported a 0% incidence of stress incontinence. I’m always skeptical of anything with a zero, but it’s pretty clear. In other procedures like TURP, where there’s more potential for human error from slips of the hand. Accidents can happen, but not with Aquablation. However, there are two aspects to consider: storage and emptying. If you have an overactive bladder and an obstructing prostate, it is always trying to empty and is pushing against the brick wall of the prostate. When you take away the brick wall, it can take a couple of months for your bladder to get used to the fact that there’s nothing blocking anymore. As a result, there are some patients who feel urinary urgency- they need to run to the bathroom- because it wasn’t a problem before because there was something blocking the way, but now it’s not there and the path is clear. The bladder has to relearn how to urinate and adjust to a new situation. So, patients can sometimes get, in rare cases, urge incontinence, which usually resolves when the bladder makes this adjustment.
Better Man Clinics: Now, let’s say I’m considering Aquablation, and I’m in your office for a consultation. What type of evaluation can I expect from you before deciding on the Aquablation procedure? Is there a specific assessment process?
Joel Hillelsohn, MD: Everyone’s unique, but my standard three-step process involves first assessing your symptoms. I want to understand how much BPH bothers you. Using a urine flow test, we measure how fast urine comes out and how much remains in the bladder after voiding. Based on this, I gauge the severity. For instance, some patients may be unaware of the risk they’re taking by urinating only 60 CCs at a time with 350 CCs left in the bladder. Others might be genuinely uncomfortable and unwilling to continue with medications. In the second step, I perform an ultrasound of your prostate to assess its shape. The third step, though often disliked, is a camera procedure called cystoscopy. This helps us to inspect the bladder and urethra. It’s crucial because unexpected findings, like bladder tumors or scar tissue, may alter the treatment plan. The goal is to determine the best procedure for you, ensuring patient-centered care and understanding that each case is unique.
Better Man Clinics: Now, let’s talk about the risks and benefits specifically related to the procedure. Can you walk me through what you usually tell patients about the risks and benefits of Aquablation?
Joel Hillelsohn, MD: Absolutely. The primary risk I emphasize is bleeding. Initially, when Aquablation was initially performed, there was a 12% return to the operating room due to bleeding. However, in the last three years, we’ve refined the approach. We now use a TURP to stop any bleeding at the bladder neck or small vessels. This significantly reduced the risk, but it’s not completely eliminated. There’s about a 2% chance of patients needing to return to the operating room for bleeding issues. It’s not severe hemorrhaging. It’s like a small bruise opening up, forming blood clots, which we want to prevent. Other risks, such as infection, are minimal, as we provide antibiotics. It’s a minimally invasive procedure, making the risks, by definition, minimal.
Better Man Clinics: Is general anesthesia is required for this procedure?
Joel Hillelsohn, MD: Yes, general anesthesia is required. We want to keep you completely still; we’re very precise. And we need you to stay still, as expected.
Better Man Clinics: Now, you mentioned that patients will stay overnight after the Aquablation procedure, which is not a big deal for one night. But I guess the good part, which doesn’t always occur with the other BPH procedures, is that the catheter comes out the next day before they go home?
Joel Hillelsohn, MD: Yes, we like to take out the catheter the next day. In 90% of my patients, that happens now. There are patients for whom we make the decision to keep them an extra night, especially since I typically perform these on Fridays. I don’t want you at home on Sunday with a catheter, trying to worry about it. The biggest issue I’ve encountered is patients complaining, and sometimes even their wives complain, saying, “What’s going on? He can’t pee straight anymore; it’s just coming out so fast.” It’s not my fault; they’ve been dealing with this big obstruction for so long. I tell them to sit down for a week, control the flow, as you’re used to it dribbling for 25 years, and now it’s a fireball. So, you need to sit down when you pee, but it’s quite normal. You may notice some blood clots here and there. I remind my patients that if you put a little fruit punch in water, it will make the whole thing look red. Don’t be scared; it’s just a clot. Urine has procoagulant properties, stopping bleeding and causing clot formation. These clots take time to dissolve, so take it easy. Most of my patients go home the next day, with no heavy lifting for two weeks, and no strenuous activity, sex, or ejaculation for three weeks. This period is crucial for healing, ensuring the prostate gets a chance to recover from the Aquablation. So, it’s essential to take it easy during this recovery period.
Better Man Clinics: Yeah, that makes sense. Obviously, we talked about minimally invasive surgery, but it’s still surgery. Once that catheter comes out, how much pain should people expect to experience after Aquablation?
Joel Hillelsohn, MD: When we talk about discomfort with urination, it depends on your perspective. Young patients with little experience of going to the bathroom frequently may find a little burning at the tip of the penis devastating. On the other hand, for someone who’s had a large prostate for many years and occasionally experiences burning, this might not be as bothersome. It’s all about managing expectations. Personally, it’s easy for me to say because I don’t have a catheter, but I promise you, you’ll feel very little. If there’s a slight burning sensation in the tip of the penis or the urge to urinate after finishing, it’s normal. The catheter removal can cause some irritation in the bladder, leading to occasional discomfort. The crucial thing is to allow your body to heal. I emphasize to my patients the importance of hydration and avoiding bladder irritants. Drink plenty of fluids, steer clear of coffee, spicy or citrusy foods, and maintain regular bowel movements to prevent constipation. Opioids are not recommended post-surgery, as they can cause constipation and offer little relief. Xanax may help with spasms, but NSAIDs like Toradol or Advil are more effective in managing bladder spasms and discomfort. While it may be uncomfortable, it’s not like the typical post-surgery incision pain associated with irritative voiding symptoms. Most patients tolerate it well.
Better Man Clinics: Now, an important question—Aqua ablation hasn’t been around for that long, so it’s hard to know long-term data. But from the data you know, how durable is Aquablation compared to other BPH procedures?
Joel Hillelsohn, MD: That’s a very good question. The Aquablation team invested in robust studies, comparing it head-to-head with TURP, a more traditional procedure. The three-year data shows that after TURP, urine flow is less than after Aquablation, indicating greater durability. Logically, it makes sense; removing more tissue leads to better outcomes. It’s a positive development and, in my opinion, Aquablation has the potential to become the gold standard for larger prostates, offering a less steep learning curve compared to other procedures.
Better Man Clinics: In terms of who performs Aquablation, is it becoming more common, or is it still a procedure done by a select group of specialists?
Joel Hillelsohn, MD: It’s growing, and the key factor influencing its adoption is insurance coverage. Hospitals need to invest in the Aquablation machine, which is a significant capital expense. Medicare started covering it about 10-12 months ago, followed by most commercial insurances around April-May and Medicaid in July-August. As coverage expands, more urologists are becoming trained. While there is a learning curve, the advantage of robotic assistance is helping to accelerate its adoption. In the next three to four years, I believe Aquablation will become the gold standard for larger prostates, with a more uniform protocol established among urologists.
Better Man Clinics: For individuals living outside the New York area, how can they find a urologist performing Aquablation?
Joel Hillelsohn, MD: Aquablation maintains an updated provider list on their website, showing urologists offering the procedure. It’s crucial to ask your urologist about their experience and the number of cases they’ve performed. While the procedure is user-controlled, having an experienced urologist is essential, as they can guide the equipment more effectively. The website is a valuable resource for patients to identify urologists offering Aquablation.
Better Man Clinics: When choosing a surgeon to perform the procedures, what is a reasonable amount of Aquablation a potential surgeon should perform before being considered proficient?
Joel Hillelsohn, MD: 15-20 cases is a good number to become proficient in Aquablation. I think the biggest challenge with Aquablation from a surgical standpoint is knowing how much to do afterwards. Otherwise, the machine does most of it. The procedure’s technology is advancing, and urologists are constantly refining the technique. Sharing experiences among a core group of urologists helps enhance the procedure’s effectiveness and minimizes the learning curve. As more cases are performed and the technology continues to improve, Aquablation is likely to become even more standardized.