Benign prostatic hyperplasia (BPH) or enlarged prostate affects half of men in their 50s, 70% in their 60s, and about 80% of men over 70 years of age. Medical and surgical treatments have been available for some time. Aquablation therapy is a new, less invasive treatment with fewer side effects. It uses water with robotic precision to remove prostate tissue without making any cuts. This therapy helps relieve BPH symptoms with a low risk of side effects. Robotic-assisted surgery gives doctors a 3D view and better movement control, leading to less pain, fewer complications, lower infection risk, quicker recovery, and minimal scarring for patients.
The surgeons at Elliot Hospital are the first in New Hampshire to use this advanced method. Dr. Christopher Girasole explains this innovative procedure.
Question: What is benign prostatic hyperplasia or enlarged prostate?
Dr. Girasole: Benign prostatic hyperplasia (BPH) is the natural and normal non-cancerous growth of the prostate gland in men as they age. It is a common and normal process, affected by genetics. As the prostate gland grows, it blocks or obstructs the bladder. The prostate gland lies just outside the bladder and surrounds the urethra. As that gland grows, the tissue gets in the way, and the bladder has a hard time emptying. Most men in their fifties and sixties will begin to experience some of these symptoms.
Question: What are the symptoms of an enlarged prostate? 
Dr. Girasole: The typical symptoms of an enlarged prostate fall into two categories: obstructive symptoms and irritative symptoms. The obstructive symptoms that we associate with BPH are a weakened urinary stream, a smaller width of the stream, and hesitancy of urination, meaning it takes a little while to get started when you pee. Some patients experience intermittency, which means that they are stopping and starting several times in the middle of their stream. Those are the most common. In a severe case, a person can’t pee. These people have significant discomfort associated with bladder stretching and need urgent attention.
The more annoying symptoms to patients tend to be the irritative symptoms. Those refer to the frequency and urgency of urination and waking up at night to pee. It makes it hard to get a good night’s sleep.
Question: Who should consider treatment for benign prostatic hyperplasia or an enlarged prostate?
Dr. Girasole: The patient’s perception of their quality of life typically drives treatment. There are some rare exceptions. Patients with significant blockage of the bladder can have long-term problems, such as stones in the bladder, leading to pain and urinary tract infections. If patients are emptying poorly and, in the worst-case scenario, if that pressure being generated in the bladder is too high, that can get transmitted up to the kidneys and cause kidney failure.
A candidate for aquablation is anybody who is bothered enough by their symptoms. Most start with medication, which can be prescribed by most primary care providers. Some providers will defer to a urologist. If a patient is concerned about their symptoms, they can certainly come to see us. We evaluate patients using a urine test, ultrasound, and physical exam to gauge the size of the prostate. Then, we simply have a discussion. Treatment depends on the patient’s goals, their anatomy, and the severity of their symptoms.
Question: What are the treatment options for an enlarged prostate?
Dr. Girasole: Treatment for BPH or enlarged prostate is either medications or procedures. Medications are effective for many. In others, they cause side effects or just do not work. Even in those for whom the medications help, there is no question that procedures tend to do a better job at relieving symptoms. In addition, given some of the long-term sexual side effects and other side effects that some of the medications can cause, a lot of men gravitate towards a procedural option. The newest and greatest procedural option is called aquablation.
Question: What is aquablation for enlarged prostate?
Dr. Girasole: In aquablation, we use high-pressure water jets to destroy prostate tissue. Aquablation is done at Elliot Hospital with anesthesia and takes less than an hour, sometimes requiring an overnight stay. A scope is placed through the urinary opening. There are no cuts or stitches.
The part that goes through the prostate shoots water jets in a circumferential fashion and destroys the prostate tissue around the scope. We also have an ultrasound probe that we put in the rectum to show us a picture of the prostate while we work. This allows us to precisely tailor the treatment to the unique shape and size of the patient’s prostate.
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Question: What is the traditional surgery for an enlarged prostate?
Dr. Girasole: The traditional surgery for the enlarged prostate is called a TURP or transurethral resection of the prostate. It uses either an electrified cutting loop or a laser to destroy the tissue.
The risk is if the surgeon is too aggressive and gets through the urethra into the sphincter muscle that wraps around the urinary channel, there is a chance they could cause incontinence or the involuntary loss of urine when you cough, laugh, or sneeze. This is very rare, but it is a possibility.
Question: Why might aquablation be safer than traditional surgery?
Dr. Girasole: Aquablation is more precise. It takes the risk of incontinence down to nearly zero. One of the other potential complications of a TURP is that the nerves that bring the signal to the penis to get rigid in response to stimulation are close by and could be damaged. After a TURP, a small percentage of patients experience erectile dysfunction.
Also, for at least 90% of men who have a TURP when they have an orgasm, nothing comes out. It does not hurt, and it does not necessarily take away from the sensation of climax, but it is a little different, and some men are bothered by that. Many medications for enlarged prostate also lead to loss of ejaculation.
The risk of this erectile side effect with aquablation is about 10%. Aquablation offers advantages over traditional medication or surgical approaches because of the precise nature of the procedure.
Question: Are there other advantages of the aquablation procedure?
Dr. Girasole: Yes, TURP is more limited by the prostate size. The prostate is about the size of a walnut in a young man. But as you age, it might grow to the size of a lime or even a grapefruit. With a large prostate, TURP cannot remove enough tissue. Aquablation can be successful even in very large prostates.
Dr. Christopher Girasole is a board-certified urologist in practice at Manchester Urology Associates.