Aquablation vs FLA

Hi andrewca

I just wanted to ask you if you saw pieces of dead tissue in the urine and if so , for how long , I have been voiding all sizes of tissue from 1/2 rice grain size to half inch since week eight after FLA with Dr K , everything is great since week seven I stopped ICC and Flomax and voiding really well , I now we are supposed to void tissue but wanted to know about you .

Hi Kissimmee,

I saw some tiny tissue particles maybe for the first 5-6 weeks, or so, but they were hardly visible, I don't see them any more or maybe I stopped noticing them recently, as all is working just fine, my urine flow rate that I think I reported before is 16.6 ml/sec, my IPSS went from 25 to 1, I stopped taking Alfuzosin some 4 weeks ago, I got RE, but I can live with this, as I had this condition before when I was on Flomax, otherwise sex life is fine, no ED, no incontinence or other side effects, I was checking a few weeks ago PVR, did 3 selfcatheterization, very little came out, maybe 20-30 ml, initially Dr.K suggested I may have to selfcatheterize for up to 6 months, likely suspecting some damage to my bladder from years of BPH, turned out I am voiding much better than he expected, so now he tells me not to try again, there is always potential for UTI, but in about 6 weeks I will do ultrasound of my bladder to confirm PVR, my FLA was on Sept 5th, Andrew

Hey Andrew just wondering where is Dr Ks office ?

Dr.K=Dr.Ara Karamanian in Houston

Truthmatters besides water vs heat there is a big difference if I understand - Aquablation is a resection of the prostate whereas FLA uses the laser to kill tissue, and the tissue flows out gradually over 6 weeks or so. So what do you mean by "Healing is considerably quicker" ? If AB is a resection presumably after initial healing it should be quicker, right?

If AB is a resection, does that mean that there is some (unavoidable) damage to the urethra?

Fred no reason to think that, the resection is on the prostate like a turp but apparently less complications - you can find info online about recent studies and from the company that markets it

It depends based on my reading up on AB and having met with a uro who performs them.If you have BPH most likely your lateral lobes in your prostate are what's causing most of the obstruction. They are, in effect, the urethra from mid-prostate up to the bladder neck area. With the exceptions of PAE and UroLift, you can't alleviate that obstruction without removing the obstructive lateral lobe tissue, and the middle lobe if present and blocking the bladder neck.

The part of the urethra that has to be avoided is the veru that lies along the posterior inner surface of the urthrea (@ 6 o'clock) distal to the later lobes and proximal to the outer sphincter at the apex of the prostate. This is where the ejaculatory ducts terminate in the urethra. It is also important that the muscular tissue surrounding the veru not be resected as it is what propels the semen from inside the urethra out the urethra.

I suspect what is happening with some of these cases where guys are getting RE after Rezum is that one or more of the injections have caused damage or ablation to occur through the path the ejaculatory duct(s) run on one side or the other. With most of these procedures the surgeon does not have a precise landmarks for where the ej ducts run through the median and/or lateral lobes to reach the veru. If the tissue through which it runs gets ablated or vaporized, then semen can't enter the urethra via the veru where it's supposed to; it exits wherever the cut in the ejaculatory duct(s) occurs, if at all. This is the one thing that concerns me about AB, all of the water jet ablation is directed sideways or downward. The ej ducts do not run through the anterior part of the prostate.

Russ I don't really understand the technical part about sideways downward and anterior part etc. All I know is that the second study that had 100 men with large prostates showed 20% RE is not terrible odds, especially since the surgeons had very little experience. You mentioned PAE and Urolift which don't seem to be effective with men who have median lobes - maybe there is a new Urolift for median lobe mentioned elsewhere I don't know how successful that one is, but PAE did not work for me - who was the Uro you spoke to if you can say or PM me ?

Mike,

Knowledge is power but paralysis by analysis is easy to do when studying the different BPH options. The studies are imperfect, but I think they ought to weigh heavily on your decision. I would guess that 20% RE is on the high side of the range. Ive seen a study for aquablation showing 2% RE. I just planned on a 10% chance.

Yes, there is definitely a urolift for median lobe. I dont prefer urolift as an approach so I havent looked at the studies. It is a strong avoider of RE.

Marty

Mike, if you watch some of the videos and animations of aquablation that are online (youtube), it is easy to see that the water jet shoots out radially from the tip of the shaft of the aquabeam device that is placed in the urethra. The water jet rotates about that axis through an angle corresponding to roughly 10 o'clock to 2 o'clock pointing downwards. In other words it spins down toward 6 o'clock, but not above towards 12 o'clock. For some reason I have not seen any of the videos showing it firing upwards towards the anterior surface (with patient lying on back) of the urethra.

Like any other procedure, how any given surgeon uses the equipment determines or has a large influence on side effects. With aquablation that is all in the programming of the ablation contours. If the surgeon programs it to sweep the entire angle the entire length of the prostate then that guy is going to have RE. If he is more conservative in planning the ablation contour then there's a good chance those parts of the prostate that need to be preserved for normal ejaculation can be spared.

There is one video of an aquablation procedure where the surgeon narrates the entire process while you see the live video from the planning software monitor, the trans-rectal ultrasound and the camera in the sheath of the device that is very helpful in understanding the procedure. I'll post the urologist's name when I can dig it up so it can be googled.

Thanks Russ I will look for the videos, although to be honest sometimes I think I'd rather not know too much graphic information - anyway I guess if one tells the surgeon you want him to plan for no RE it should reduce the chance of RE. I keep worrying about the large median lobe sticking into bladder, if they need to get to that and it's upwards like you say there may not be any way to avoid blowing away the ejaculatory ducts or whatever they are called.

Both of these are on youtube:

Aquablation therapy Overview by Dr. Mihir Desai

Aquablation: Image guided robot-assisted water-jet ablation of the prostate by Dr. Rijo

It helps if you understand the views you see on the TRUS video before you watch it. Transverse view is looking from front of body to back or vice versa; sagital view is looking from one side of the body through to the other. If you look in the lower right hand corner of the aquabeam software user interface you'll see a pair of opposing arrows that are either pointing up and down in which case you're looking at the transverse view; if they're pointing sideways you're looking at the sagital view. The arrows are labeled "neck" for bladder neck and "veru" for verumontanum, which is the landmark in the apex where the ejaculatory ducts exit into the urethra and is just "north" of the voluntary outer sphincter that provides continence. I find it helpful to think of the transverse view as being taken from a camera above looking down on the patient's abdomen while the sagital view is what it would look like from a camera pointed horizontally at the patient's side.

Pretty fascinating stuff to watch.