Aquablation for bph, enlarged median lob, urgency and frequency

Men's health
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I am a 69 year old male with an enlarged prostate (BPH), median lobe growing into bladder (intravestical prostatic protrusion or IPP), overactive bladder, urinary urgency and frequency.

Is Aquablation the best way to surgically repair this situation while maintaining complete sexual function with normal orgasm and without incontinence?

I live in the NYC, Nassau County area. I would like to hear from men who had their enlarged prostate, with enlarged median lobe (BPH and IPP )treated with Aquablation and their success rate. If you had a successful Aquablation for this problem, in my area who did you use?

I am considering Bilal Chughtai, M.D., Alexis E. Te, M.D. at Cornell or Steven Kaplan, M.D. at Mount Sinai.

I am really frustrated by the urgency, frequency and really want to treat this problem. I had two coronary stent placements in July 2021. In 4 months I can stop my anti platelet medication to have this procedure.

What are the pros and cons? Thanks!

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@newzev4 Hey, newzev, I looked at Aquablation before deciding on Holep. 71 yrs, with your exact anatomy. Symptoms are identical. I thought aquablation risked hemostatis.

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I had an aquablation procedure on January 12th this year with Dr. Steven Kaplan. My treatment objectives were 1.) efficacy; 2.) durability; 3.) preservation of continence; 4.) preservation of erectile function and; 5.) preservation of ejaculatory function. I had a 118 gram prostate and a very large median, obstructive median lobe, and some pre-op storage symptoms, including nocturia, frequency and urgency. I have had a great recovery with little or no issues. Kaplan & team are outstanding. I could not be happier with my outcome. I would be happy to discuss more as warranted. Cheers.

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I cant speak to your specific issues but I had Aquablation 2.5 weeks ago at Georgia Urology near Atlanta. Dr explained to me that the procedure would most probably fix the obstruction issue immediately(ie any inability pee a full steady stream) but the storage issues( urgency , frequency overactive bladder)will take time to resolve themselves as your bladder has to relearn the signals that cause it to begin the emptying process. Good luck with whatever you choose to do.

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Hi Carl, It is nice to know I am not alone with my condition. A little background that affects my decision: I’m 69 years old with 3 coronary stents, the 2 most recent last July. In 5 months I can stop my anti-platelet medication, so that I can finally consider a urological intervention. But, I need to choose the most suitable procedure and physician. I now take Praulent injections which have lowered my cholesterol to 78 and LDLS to 0 which hopefully will help me avoid future cardiac interventions. I mention the stents due to my concern of hemostatis as well. A bit of searching on the internet indicates that some urologists actually go in and cauterize bleeding post-Aquablation, but probably not as well as done in a HOLEP?Did HOLEP reduce urinary frequency, urgency and Nocturia and affect orgasm ? I wonder how similar types of procedures such as bi- polar turp, green laser, and other resection procedures, compare to HOLEP. I am also considering prostate artery embolization (PAE). It seems Aquablation or PAE would least likely affect sexual function. But, equally important to me is reduction in urinary frequency and urgency. There seems to be differing opinions as to whether PAE is that effective when a median protastic lobe protrudes into the bladder. Once again, Carl thank you for your thoughts.

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Mike, that is WONDERFUL news. I am so happy for you!!! Okay, I have the same objectives. I want to maintain sexual function, including normal orgasm, and reduce frequency and urgency. I want to be able to get on with my life without have to consider where the nearest bathroom or find a discrete place to pee because the urgency suddenly comes on.. My prostate is about 40-50 grams. I have a median lobe that protrudes into my bladder. A few years ago I was told, after a lot of tests, that my best choices would be bi-polar turp, Rezum or prostate artery ablation. At that time I was not ready. Now, I am leaning to Aquablation by either Steve Kaplan, Bilal Chugtai. or Alexis Te. I have a local urologist in Long Island who is disapproves of Aquablation. In his group they had only done a total of 7 Aquablations. He said one of them perforated the patient’s bladder, so he does not recommend the procedure. So I contacted Dean Elterman at Toronto (who used to be in NY). In Medifind Dr. Elterman is listed as an Elite doctor for performing Aquablations. So I asked him about the possiblity of a perforation of a bladder. He never had that happen. He immediately recommended Steve Kaplan at Mt Sinai. He then said if I have an Aquablation at either Mount Sinai or at Cornell ( he said both institutions are super users of Aquablation) I will be likely very pleased with the outcome. I said I was also considering Bilal Chugtai or Alexis Te at Cornell. He told me he trained under both these doctors and both would be excellent choices as well. Thanks again Mike. It is comforting to know there are others out there with a combination of BPH and median lobe issues, that have the same symptoms as me, but more importantly that you can get this problem fixed without ED, dry orgasms or incontinence. Thank goodness for this forum.

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Hi Bob,

It sounds like it will take a while to know. As more time passes please share your experience with us . Thanks

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@newzev, Sorry to hear about heart issues. Ones health is so important and comorbidities. My post experience with Holep-En Bloc is still early. The pros are: great pressure at the pump:) you’ve heard of a firehose? the urinary retention is non existent; urgency about what it was before BUT only 10 days since procedure and hoping for better 6-8 weeks out. I do think the success of urological procedure is matching the proper procedure with patients anatomy. I have spend 10 years thinking and studying to get to this point. My studies always came back saying PAE and forms of Urolift would NOT work with my small prostate (35cc), obstructive median lobe protruding into bladder neck. Now, satisfied, but not what I need in nocturia. Only, time will tell. Aquablation with that cauterizing the vessels would be my big issue.

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I had Aquablation therapy 18 months ago and can address your questions.

I had a large median lobe that protruded into my bladder between 1 & 2 centimeters. The planning software for the Aquabeam robot allows the surgeon to map out the resection surface specifically for the median lobe. Surgeons run two passes of the water jet on most patients. This is effective in patients whose median lobe is “floppy” and may not have been completely disintegrated on the first pass. It’s very obvious when you compare the ultrasound video recorded during the planning stage to that after the waterjet has finished its 2nd pass that where there was previously nearly total obstruction there is now a wide open channel into the bladder. I also saw this effect first hand about 6 weeks after my surgery when my doctor did an in-office flexible cystoscopy to see if he could find any remnants of urolift implants he might have missed during the Aquablation procedure. There was a huge cavity once the camera got about a centimeter past the veru. My average flow rate increased from 3 ml/sec prior to surgery to around 20 ml/sec after.

Bleeding was an issue with Aquablation on larger prostates early on, several years ago, when they were trying to use only compression from a balloon in traction to control bleeding. For the past 2-3 years they have been doing spot cautery in one area of the bladder neck only where arteries are known to be. They use a loop to remove what they call white fluffy tissue left over from the water jet in order to uncover the arteries that are the main source of bleeding so they can be cauterized. There was a meta analysis done by Elterman and the Canadian researchers that compiled the stats for transfusions needed over the course of thousands of Aquablation cases once the hemostasis technique was revised that showed the transfusion rate to be less than 0.8%. This is comparable to or less than what is seen with TURPs and Greenlight PVPs. In my case my Foley bag was light pink the next day and I was released to go home less than 24 hours after the procedure.

I had no sexual side effects from the surgery.

The only “cons” I can think of with Aquablation are that it does require anesthesia and although some docs are learning how to do same day discharge cases, in your case an overnight stay in the hospital would be very likely with your heart issues. I actually viewed that as a benefit since I knew if I had any issues that first night professional help was only seconds away.

If you haven’t already I’d strongly recommend you talk with Mike who responded to your post and had his Aquablation done recently by Dr Kaplan. I had mine done in the Atlanta area.

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I just had Aquablation on the 17th. My Foley was removed yesterday, the 23rd. Before the procedure, I was no able to urinate at all and have been self cathing for 22 months. So far, I am able to urinate a small amount on my own, except that it’s a few ounces at a time and I get the urge every 30-45 minutes. My Uro suggested continuing to cathe until “things improve”. Will they improve? If the obstruction was removed, shouldn’t I be voiding better? I’m worried that this may not be successful. Has anyone else had this and improved? I already had Rezum last August with no benefit at all. I can’t have another procedure again.

Ted

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You probably have some inflammation from the ablation. I failed my 1st void test because of that but after starting to take some Naproxin (NSAID) I was able to completely empty my bladder at 20 ml/sec. As one of my urologists said, “You just had prostate surgery, it’s not supposed to be easy.”

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Thanks, that gives me more hope. As of today, nothing has changed as of yet.

Ted

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Hi Mike,

I was told Dr Kaplan is the voiding expert - he writes books on this for other doctors, so I had him do a cystoscopy and urodynamics in Aug 2021.

I am considering several different BPH surgeries but I have a markedly distended bladder and supposedly pelvic floor dysfunction, which Dr Kaplan said is caused by years of me overcompensating in trying to empty.

After these tests Dr Kaplan said my issue is not complicated. He would do an electro vaporization of the prostate and said my pelvic floor symptoms would disappear but I still should do pelvic therapy after.

Did you have any of the above and also can you provide us with an update on your Aquablation since it is now one month later?

Did you have any need to contact him while recovering at home and how quick and compassionate were his response(s)?

Is electro vaporization of the prostate the Aquablation procedure?

Thanks

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Hi Bob.

Hi Mike,

Can you provide us with an update on your Aquablation since it is now 6 weeks later?

Is electro vaporization of the prostate the Aquablation procedure?

Thanks

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Hi Ted,

As 5 weeks have passed, can you provide an update on your Aquablation?

Thanks

Bob

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Hi Bob,

Sorry for the delay, but it seems even though my setting is to receive new message notifications, I never received your message.

I was going to do a Rezum, but too many doctors have said either it’s not good for median lobe obstruction (even though the Rezum site states it is), then I was scheduled for a MOSES Holep at Mayo Clinic in AZ (I live in NJ).

I am really stressed out because all the doctor’s are recommending surgeries that have retrograde ejaculation risk of between 50% and 100%!

So I would now like to consider Aquablation. Electrovaporization of the prostate is not Aquablation. It is a TURP.

For those reading this who had an Aquablation, did you need to do self catherization at home and if so, for how many days? Did you need to self catherize even before surgery?

Were you able to avoid retro ejaculation?

Do you know your prostate size? Mine is small, 30 grams.

Anyone else reading this who could share their Aquablation experience here, would be very helpful to me.

Thank you so much.

Bob

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Hi folks - I am now 4.5 months out from my Aquablation procedure. I really don’t have any post-op issues and everything is going quite well. I am able to sleep through the night most nights, and have no sexual or other complications. My bladder is continuing to happily adjust to its “new normal” of no obstruction. I have the ability to contact Dr. Kaplan’s office as needed but have not really had much of a need. In summary, I have had a great experience with Kaplan and Aquablation, and BPH is no longer an issue for me. Thanks. Mike

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Hi Mike,

That is so wonderful to hear!!

Did you have any pelvic floor dysfunction as I do and is that or has that resolved after your surgery?

What was the size of your prostate and did you have a median lobe obstruction? Mine is small, 30 gms.

I had a telehealth call with Dr Kaplan about 10 days back with questions I had on my Urodynamics and Cystoscopies and he was very helpful. I think I asked about Aquablation instead of electrovaporization as he suggested for me and I think he said it’s too new - unfortunately I didn’t write what he said so I’ll have to message him.

Also, he doesn’t want to do surgery on me because during the Urodynamics his tech could not insert the scope/catheter. Eventually she did. However, when the tests were over and I removed the sheet over my lower half, I was covered in blood!

Underwear, thighs, legs, even my socks!

One of the temporary side effects is you might see some blood in your urine - I know, I have had several of these tests over 20 yrs and know what is normal. But this time I actually had blood dripping from my penis the entire day and night after I returned home! I knew this was not normal, plus I was in more than normal discomfort and was awakening 8-10x compared to 3-4x before these procedures.

Long story short, after 4 weeks of suffering, I contacted my NJ urologist and he ordered a culture. I had gotten a UTI from the tests! I never had a UTI before in my entire life.

I reported this to Dr Kaplan but he failed to respond. Then I called, and even emailed, but no replies. I have no idea why he would ignore a patient.

It seems for some reason, because I became anxious as my symptoms became worse over time, he thinks my personality will not suit him and he will not perform surgery for me.

Bob

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Hello Bob,

I’m at 10 weeks now and things have improved slightly but not as well as I would have liked. My urgency and frequency is less. I can go on average about 90 minutes between voids. I am still retaining 200 -300 cc of urine. I am still cathing two times a day. The recommendation is to keep the course and “hope” that my bladder retrains.

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Hi Ted,

Sorry to hear that. I’ve been told by several doctor’s your bladder needs to relearn that it doesn’t need to empty as often after many years of doing so.

And that how much it relearns only time can tell.

Were you self-cathing before the Aquablation?

How many times did you awaken to use the bathroom before and now after surgery?

Hope things keep going in the right direction for you.

Bob