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Name:
Aquablation Treatment for Benign Prostate Hyperplasia - Standardized Procedure
Description:
Aquablation Treatment for Benign Prostate Hyperplasia - Standardized Procedure
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T00H24M02S
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Upload Date:
2024-04-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Introduction.
DR. KEVIN ZORN: Aquablation therapy for BPH. Atlas of minimally invasive urological surgery. Presentation by Dr. Kevin Zorn, professor of Urology at the University of Montreal.
Segment:2 Indications.
DR. KEVIN ZORN: Indications for aquablation vary by terminology. In the United States and Hong Kong, for the intended use of resection and removal of prostate tissue in men suffering from LUTS due to BPH. And for the remainder of the world, indication of AquaBeam robotic treatment is intended for the resection and removal of prostate tissue in men suffering from LUTS.
DR. KEVIN ZORN:
Segment:3 Equipment.
DR. KEVIN ZORN: The standard equipment for the AquaBeam robotic system includes the actual robotic PROCEPT device, the individual AquaBeam handpiece, which is a 24 French sized equipment, which will be shown later, including the digital cystoscope also furnished by PROCEPT BioRobotics. Furthermore, the transrectal ultrasound with bi-plane device will also be needed for real time planning and execution of the procedure.
DR. KEVIN ZORN: Furthermore, two articulating, table mounted arms for stabilizing and locking the handpiece, as well as the trend rectal probe are needed. At the completion of AquaBeam treatments, monopolar or bipolar resectoscope loop is needed followed by Toomey syringe or an Ellik evaluator in order to remove the clots of hematuria. Finally, a catheter is needed for the final placement and for monitoring of continuous bladder irrigation after the procedure.
DR. KEVIN ZORN: Also, a syringe for lubricant is needed for the safe placement of the trend transrectal ultrasound probe at the commencement of the procedure.
Segment:4 Patient Positioning.
DR. KEVIN ZORN: Patient positioning. Once anesthesia is achieved, lithotomy is the position of choice for this procedure. Careful use of stirrups for proper positioning and pressure point monitoring are required. It is important to make sure that the patient is centered and flushed with the end of the operative table so as to optimize the working space for both the transrectal ultrasound and the handpiece transurethrally.
DR. KEVIN ZORN: The height of the table is also needed to be adjusted so to be as comfortable for the procedure for both the patient and the physician. With regards to anesthesia, it is highly recommended to use a general anesthesia with neuromuscular blockade to ensure that the patient does not move at all during the procedure with both the handpiece and transrectal ultrasound in place. Ultimately is at the discretion of the surgeon and spinal anesthesia can also be used.
DR. KEVIN ZORN:
Segment:5 Instrument Set Up.
Segment:6 Prime Handpiece.
DR. KEVIN ZORN: Instrument setup. Once the operation is prepped and draped in the usual sterile fashion, it is important to prime the AquaBeam handpiece with the AquaBeam scope into its fully extended tube position to ensure that the tip is advanced to the furthest end of the nozzle. This can be seen on the bottom photo with the AquaBeam scope and the nozzle to its full extended position.
DR. KEVIN ZORN: At that point, direct the tip of the AquaBeam handpiece away from the patient or the user towards a fluid collection container and by this way, ensuring that the device is primed and all air is removed. Simultaneously, press the prime button on the foot pedal and the plus button on the motor pack for 100% power.
Segment:7 Insert transrectal ultrasound.
DR. KEVIN ZORN: Instrument setup. At this point, insert the transrectal ultrasound probe with 60 ccs of lubricant into the rectal space and position the TRUS stepper fully distally. Ensure that the TRUS probe is centered on the cradle. Insert the transrectal ultrasound probe in the transverse view. And then again, center the TRUS from the mid prostate to the bladder.
DR. KEVIN ZORN: So once the transrectal ultrasound probe is fully inserted, switch to the sagittal plane to ensure that the entire prostate is visible. At this point, once the probe is in position, we can then validate that the entire prostate is fully seen on both the sagittal and transverse positions for next step procedure. Instrument setup.
Segment:8 Drape the equipment.
DR. KEVIN ZORN: At this point, it is important to drape both the articulating arms of the device, as well as the patient, the TURP drape, in the PROCEPT lithotomy drape. This can be seen here in the video demonstrating the necessary equipments for the draping and sterility of the procedure, as well as the various other surrounding equipments.
Segment:9 Insert the AquaBeam handpiece.
DR. KEVIN ZORN: Instrument setup. At this point, it is important to have the primed handpiece and the scope then placed under guidance through the urethra as can be seen in the top right to visualize the verumontanum. And then, to advance into the bladder so that the tip of the scope should be at least 1 to 2 centimeters beyond the prostate tissue. During this time, the calibration of the scope at the verumontanum is confirmed on the sagittal view of the ultrasound so as to be able to protect and understand clearly the position of the sphincter throughout the entire procedure.
DR. KEVIN ZORN: Mount the handpiece to the 12:00 o'clock, as scene in the top right video, of the prostatic urethra to ensure the proper positioning of the scope. Make sure to ensure turning off all irrigation during this time. This next summary slide demonstrates the proper positioning of the handpiece where the tip of the working instrument is at least 1 centimeter beyond the prostate and its most anterior position at 12:00 o'clock position of the prostatic urethra is essential.
DR. KEVIN ZORN: The bottom right of the images demonstrates the camera, which is parked at the verumontanum, demonstrating the scope is also located at the 12:00 o'clock position of the urethra. Surgical steps.
Segment:10 Surgical Steps.
Segment:11 Optimize the TRUS image and Visualize & Align the Waterjet.
DR. KEVIN ZORN: Optimize the transrectal ultrasound to align with the handpiece.
DR. KEVIN ZORN: Apply compression as needed. Ensure that the blotter and the scope can be visualized in the sagittal image. At this point, it is important then to align the water jets and visualize an ultrasound. This can be seen on the ultrasound images at this point, where two hyperechoic artifacts are visible.
DR. KEVIN ZORN: And by the surgeon pressing the foot pedal, the water jets should be seen alternating at the 3:00 and the
9: 00 o'clock positions,
9: ensuring the proper horizon and orientation. This next slide demonstrates the alignment or positioning of the transrectal ultrasound so as to align with the AquaBeam handpiece. This calibration is essential. The bottom right image demonstrates the hyperechoic ultrasound images of the handpiece along with the water beam jet, which is now being released to the 3:00 o'clock position, with the white blur confirming the orientation of the waterjet.
9: Calibration can be made using the cradle and rotating if needed.
Segment:12 Angle planning in Transverse view.
9: Surgical setup. Angle planning in the transverse view. At this point, the surgeon will orient in the transverse ultrasound view one of the larger areas of the prostate with the alignment of the handpiece and with the-- using the toggles to orient the depth and maximal angle wished for during treatment.
9: The markers will help designate the area of treatment in the transverse view. Waterjet nozzle registration.
Segment:13 Waterjet Nozzle Registration.
9: At this point, the surgeon will activate the waterjet in the bladder and perform nozzle registration. Once that's complete, the designation on ultrasound of the scope will be confirmed.
9: If the waterjet cannot be seen, press the right arrow key on the keyboard to retract a waterjet nozzle into the mid-prostate and then perform nozzle registration.
Segment:14 Contour Planning in Sagittal view.
9: Contour planning. One of the most crucial steps of the procedure is designating the treatment plan in the sagittal view. Position the scope at the external sphincter and identify the start treatment in the most distal portion of the prostatic tissue, the bladder neck, the midprostate largest portion of the prostate, the verumontanum, and the scope tip.
9: After clicking Next, a suggested treatment plan is offered and the surgeon has the ability to move and reposition depth markers. Notice the area in orange here, which is the apical tissue treatment, and the butterfly cats near the verumontanum so as to preserve integrated ejaculation. So careful adjustments are needed in the case of large meaty lobes, larger prostates, and certainly those with more protruding tissue at the apex.
9:
Segment:15 Treatment First Pass.
9: First pass. At this point, activate the waterjet by stepping on the foot pedal. The waterjet will follow the treatment plan. Adjustments can be offered or suggested by using the plus or minus signs on the handpiece if further treatment is needed. Note that the waterjet stops at the verumontanum in the orange section and does the two contralateral butterfly cuts to preserve the verumontanum.
9: As can be seen, there's also a time suggestion that the treatment is being conducted, as can be seen on the left. So a real time evaluation of the planned treatment for the first pass as it moves its way from the bladder neck back to the verumontanum. And that last segment, the butterfly cut, will be only preserved, only performed on the ipsilateral side.
9: So at this point, as could be seen on the top right image, the treatment is only on the patient's right side. The water beam is only being deflected to the right side then we'll retract back to about a centimeter and a half and then perform the same butterfly cuts on the patient's left side so as to not do any treatment toward the 6:00 o'clock position and therefore injure the verumontanum and ejaculatory ducts.
9:
Segment:16 Treatment Second Pass.
9: Treatment, second pass. At this point, it is suggested that the surgeon reviews changes to the anatomical structures and makes further adjustments if needed for the treatment markers. This may take a minute or so, and in certainly larger prostates, deflecting the hand piece down so as to create a larger cavity.
9: Once-- those adjustments are all complete, activate the waterjet by stepping on the foot pedal once again and performing a second treatment. So here are the video demonstrates the handpiece in position and then retracted after the second treatment to commence with the irrigation and hemostasis.
9: To this point, the cystoscope is then placed and the Ellik use to remove any clots in preparation for the transurethral resection loop for good hemostasis.
9: To this point, the TURP loop is then placed after declotting. Then the surgeon uses the standard TURP loop with electrocautery to reform focal cautery, particularly at the bladder neck, at the
5: 00 and 7:00 o'clock positions.
5: Use of resection at the same locations are also important to remove some of the fraudulent fluffy tissues to uncover the significant blood vessels in those areas. At this point, we move into the hemostasis segment,
Segment:17 Focal Bladder Neck Cautery - Hemostasis.
5: which is key for optimizing hemostatic control and minimizing any subsequent complication, particularly of sexual functions.
5: So as mentioned, prepare prior to the completion of the second pass of the activation the resectoscope into syringe. Irrigate the bladder and remove all clots, and then insert the resectoscope. The key here is starting at the bladder neck and focusing on the significant blood vessels in that area. Remove the fluffy tissue, be it mechanically or using the TURP electrocautery loop, and then using cautery specifically of those significant vessels.
5: So here, the surgeon is starting and looking at the floor of the bladder neck not to encroach further back toward the apex or midsection and simply removing the tissues around that bladder neck to uncover the more familiar bladder neck fibers, and thereby localizing the one or two significant arterial vessels that would be the source of that bleeding.
5: So then, again, using selective cautery at the bladder neck to ensure optimal hemostasis prior to catheter insertion. So here after resecting, no more do we see the fluffy tissues but the typical bladder fibers we would normally see during a standard TURP. Occasionally, due to large amounts of anterior tissue, the surgeon may also deem it necessary to do anterior resection of the prostatic urethra for significant adenoma in that area.
5: Again, taking the time necessary during these 5 or 10 minutes are important to ensuring a smooth post-op recovery for these patients. Here, you can see a significant vessel cauterized taking the time necessary in the bladder neck cautery, which is the source of most significant blood bleeding after TUR resections.
5: Use of a continuous sheath is also suggested so as to minimize bladder overdistension and the need for repetitive unlocking, removal of the full bladder, and then repeating. So a continuous resectoscope sheath is highly recommended.
5: As mentioned, search for the fluffy tissues at the bladder neck. Use the loop to remove that fluffy irregular tissue post-op aquablation. And then, use the cautery selectively to cauterize those significant arterial bleeding sources. This is usually done several times, ensuring that the significant blood vessels or cauterize so as to allow for shorter hospitalization and shorter catheter timing.
5: So the efflux should be a light pink by the end of the procedure. Otherwise, suggestion to the surgeon is to continue repeating until all blood vessels are controlled.
Segment:18 Post Operative Care.
5: Post-operative care. Once the aquablation therapy and the hemostasis are complete, a three-way hematuria catheter should be placed, where the balloon is filled to 30 or 60 ccs in the balloon and that continuous bladder irrigation is commenced.
5: Commonly used catheters include the Rusch, 22 French, 24 French, or the BARD system. There's also the 24 French Coloplast x Flo. Suggestion is at the discretion of the treating surgeon and their comfort. The catheter is then secured with variable traction, either to leg or wet gauze synced against to ensure crystal clear urine to light red at the end of the procedure for the irrigation.
5: Some physicians will use a BNO suppository, Belladonna and Opioid, to help ensure that the patient have comfort with the catheter position and improve patient compliance and comfort. The patients is then admitted to the PACU for up to 3 to 4 hours of continuous bladder irrigation and monitoring by the nursing team. It is important to continue to monitor blood pressure and patient comfort and their BP medications prior to the procedure.
5:
Segment:19 Potential for Same Day Discharge.
5: Potential for same day discharge. Key opinion leaders have previously reported a white paper on this topic. But after the 4 hours of CBI, the decision algorithm is used as outlined on the right. If the degree of hematuria is not clinically significant, either a grade I, II, or III, as seen on the bottom right, in the red, 10 minutes after clapping the irrigation, the patients can be discharged home.
5: For those patients with a grade IV or grade v, significant bleed observation after being admitted is necessary, and the potential for returning back to the operating room should be considered by the treating surgeon.
Segment:20 Clinical Outcomes.
5: From the clinical outcomes, we know from the WATER I, the randomized controlled trial versus TURP, with now five year outcomes, the surgical retreatment rate is 5% and the medical retreatment rate is only 1%.
5: IPSS improvements dropped by 15 points, a 69% reduction, similar to the quality of life improvements and with a dramatic 125% greater q-max compared to baseline. What was very impressive is the low ejaculatory dysfunction rate notably from the butterfly cuts and anatomic respect for the apical tissues. Note, no patient had any reported erectile dysfunction or incontinence.
5: For the WATER II trial, for the single arm, four year now outcomes of men with prostates, over 80 grams up to 150 grams, note the surgical retreatment rate of only 3%, the medical BPH treatment rate of 6%, and very similar improvements both in IPSS, quality of life, and q-max urinary flow. Ejaculatory function was a little bit higher at 15%. Still, notably improved compared to the counterparts of hold up, TURP, or green light laser with much higher ejaculatory dysfunction rates, and again, very respectable low to non-existent erectile dysfunction or incontinence Thank you.
5:
Segment:1 Introduction.
DR. KEVIN ZORN: Aquablation therapy for BPH. Atlas of minimally invasive urological surgery. Presentation by Dr. Kevin Zorn, professor of Urology at the University of Montreal.
Segment:2 Indications.
DR. KEVIN ZORN: Indications for aquablation vary by terminology. In the United States and Hong Kong, for the intended use of resection and removal of prostate tissue in men suffering from LUTS due to BPH. And for the remainder of the world, indication of AquaBeam robotic treatment is intended for the resection and removal of prostate tissue in men suffering from LUTS.
DR. KEVIN ZORN:
Segment:3 Equipment.
DR. KEVIN ZORN: The standard equipment for the AquaBeam robotic system includes the actual robotic PROCEPT device, the individual AquaBeam handpiece, which is a 24 French sized equipment, which will be shown later, including the digital cystoscope also furnished by PROCEPT BioRobotics. Furthermore, the transrectal ultrasound with bi-plane device will also be needed for real time planning and execution of the procedure.
DR. KEVIN ZORN: Furthermore, two articulating, table mounted arms for stabilizing and locking the handpiece, as well as the trend rectal probe are needed. At the completion of AquaBeam treatments, monopolar or bipolar resectoscope loop is needed followed by Toomey syringe or an Ellik evaluator in order to remove the clots of hematuria. Finally, a catheter is needed for the final placement and for monitoring of continuous bladder irrigation after the procedure.
DR. KEVIN ZORN: Also, a syringe for lubricant is needed for the safe placement of the trend transrectal ultrasound probe at the commencement of the procedure.
Segment:4 Patient Positioning.
DR. KEVIN ZORN: Patient positioning. Once anesthesia is achieved, lithotomy is the position of choice for this procedure. Careful use of stirrups for proper positioning and pressure point monitoring are required. It is important to make sure that the patient is centered and flushed with the end of the operative table so as to optimize the working space for both the transrectal ultrasound and the handpiece transurethrally.
DR. KEVIN ZORN: The height of the table is also needed to be adjusted so to be as comfortable for the procedure for both the patient and the physician. With regards to anesthesia, it is highly recommended to use a general anesthesia with neuromuscular blockade to ensure that the patient does not move at all during the procedure with both the handpiece and transrectal ultrasound in place. Ultimately is at the discretion of the surgeon and spinal anesthesia can also be used.
DR. KEVIN ZORN:
Segment:5 Instrument Set Up.
Segment:6 Prime Handpiece.
DR. KEVIN ZORN: Instrument setup. Once the operation is prepped and draped in the usual sterile fashion, it is important to prime the AquaBeam handpiece with the AquaBeam scope into its fully extended tube position to ensure that the tip is advanced to the furthest end of the nozzle. This can be seen on the bottom photo with the AquaBeam scope and the nozzle to its full extended position.
DR. KEVIN ZORN: At that point, direct the tip of the AquaBeam handpiece away from the patient or the user towards a fluid collection container and by this way, ensuring that the device is primed and all air is removed. Simultaneously, press the prime button on the foot pedal and the plus button on the motor pack for 100% power.
Segment:7 Insert transrectal ultrasound.
DR. KEVIN ZORN: Instrument setup. At this point, insert the transrectal ultrasound probe with 60 ccs of lubricant into the rectal space and position the TRUS stepper fully distally. Ensure that the TRUS probe is centered on the cradle. Insert the transrectal ultrasound probe in the transverse view. And then again, center the TRUS from the mid prostate to the bladder.
DR. KEVIN ZORN: So once the transrectal ultrasound probe is fully inserted, switch to the sagittal plane to ensure that the entire prostate is visible. At this point, once the probe is in position, we can then validate that the entire prostate is fully seen on both the sagittal and transverse positions for next step procedure. Instrument setup.
Segment:8 Drape the equipment.
DR. KEVIN ZORN: At this point, it is important to drape both the articulating arms of the device, as well as the patient, the TURP drape, in the PROCEPT lithotomy drape. This can be seen here in the video demonstrating the necessary equipments for the draping and sterility of the procedure, as well as the various other surrounding equipments.
Segment:9 Insert the AquaBeam handpiece.
DR. KEVIN ZORN: Instrument setup. At this point, it is important to have the primed handpiece and the scope then placed under guidance through the urethra as can be seen in the top right to visualize the verumontanum. And then, to advance into the bladder so that the tip of the scope should be at least 1 to 2 centimeters beyond the prostate tissue. During this time, the calibration of the scope at the verumontanum is confirmed on the sagittal view of the ultrasound so as to be able to protect and understand clearly the position of the sphincter throughout the entire procedure.
DR. KEVIN ZORN: Mount the handpiece to the 12:00 o'clock, as scene in the top right video, of the prostatic urethra to ensure the proper positioning of the scope. Make sure to ensure turning off all irrigation during this time. This next summary slide demonstrates the proper positioning of the handpiece where the tip of the working instrument is at least 1 centimeter beyond the prostate and its most anterior position at 12:00 o'clock position of the prostatic urethra is essential.
DR. KEVIN ZORN: The bottom right of the images demonstrates the camera, which is parked at the verumontanum, demonstrating the scope is also located at the 12:00 o'clock position of the urethra. Surgical steps.
Segment:10 Surgical Steps.
Segment:11 Optimize the TRUS image and Visualize & Align the Waterjet.
DR. KEVIN ZORN: Optimize the transrectal ultrasound to align with the handpiece.
DR. KEVIN ZORN: Apply compression as needed. Ensure that the blotter and the scope can be visualized in the sagittal image. At this point, it is important then to align the water jets and visualize an ultrasound. This can be seen on the ultrasound images at this point, where two hyperechoic artifacts are visible.
DR. KEVIN ZORN: And by the surgeon pressing the foot pedal, the water jets should be seen alternating at the 3:00 and the
9: 00 o'clock positions,
9: ensuring the proper horizon and orientation. This next slide demonstrates the alignment or positioning of the transrectal ultrasound so as to align with the AquaBeam handpiece. This calibration is essential. The bottom right image demonstrates the hyperechoic ultrasound images of the handpiece along with the water beam jet, which is now being released to the 3:00 o'clock position, with the white blur confirming the orientation of the waterjet.
9: Calibration can be made using the cradle and rotating if needed.
Segment:12 Angle planning in Transverse view.
9: Surgical setup. Angle planning in the transverse view. At this point, the surgeon will orient in the transverse ultrasound view one of the larger areas of the prostate with the alignment of the handpiece and with the-- using the toggles to orient the depth and maximal angle wished for during treatment.
9: The markers will help designate the area of treatment in the transverse view. Waterjet nozzle registration.
Segment:13 Waterjet Nozzle Registration.
9: At this point, the surgeon will activate the waterjet in the bladder and perform nozzle registration. Once that's complete, the designation on ultrasound of the scope will be confirmed.
9: If the waterjet cannot be seen, press the right arrow key on the keyboard to retract a waterjet nozzle into the mid-prostate and then perform nozzle registration.
Segment:14 Contour Planning in Sagittal view.
9: Contour planning. One of the most crucial steps of the procedure is designating the treatment plan in the sagittal view. Position the scope at the external sphincter and identify the start treatment in the most distal portion of the prostatic tissue, the bladder neck, the midprostate largest portion of the prostate, the verumontanum, and the scope tip.
9: After clicking Next, a suggested treatment plan is offered and the surgeon has the ability to move and reposition depth markers. Notice the area in orange here, which is the apical tissue treatment, and the butterfly cats near the verumontanum so as to preserve integrated ejaculation. So careful adjustments are needed in the case of large meaty lobes, larger prostates, and certainly those with more protruding tissue at the apex.
9:
Segment:15 Treatment First Pass.
9: First pass. At this point, activate the waterjet by stepping on the foot pedal. The waterjet will follow the treatment plan. Adjustments can be offered or suggested by using the plus or minus signs on the handpiece if further treatment is needed. Note that the waterjet stops at the verumontanum in the orange section and does the two contralateral butterfly cuts to preserve the verumontanum.
9: As can be seen, there's also a time suggestion that the treatment is being conducted, as can be seen on the left. So a real time evaluation of the planned treatment for the first pass as it moves its way from the bladder neck back to the verumontanum. And that last segment, the butterfly cut, will be only preserved, only performed on the ipsilateral side.
9: So at this point, as could be seen on the top right image, the treatment is only on the patient's right side. The water beam is only being deflected to the right side then we'll retract back to about a centimeter and a half and then perform the same butterfly cuts on the patient's left side so as to not do any treatment toward the 6:00 o'clock position and therefore injure the verumontanum and ejaculatory ducts.
9:
Segment:16 Treatment Second Pass.
9: Treatment, second pass. At this point, it is suggested that the surgeon reviews changes to the anatomical structures and makes further adjustments if needed for the treatment markers. This may take a minute or so, and in certainly larger prostates, deflecting the hand piece down so as to create a larger cavity.
9: Once-- those adjustments are all complete, activate the waterjet by stepping on the foot pedal once again and performing a second treatment. So here are the video demonstrates the handpiece in position and then retracted after the second treatment to commence with the irrigation and hemostasis.
9: To this point, the cystoscope is then placed and the Ellik use to remove any clots in preparation for the transurethral resection loop for good hemostasis.
9: To this point, the TURP loop is then placed after declotting. Then the surgeon uses the standard TURP loop with electrocautery to reform focal cautery, particularly at the bladder neck, at the
5: 00 and 7:00 o'clock positions.
5: Use of resection at the same locations are also important to remove some of the fraudulent fluffy tissues to uncover the significant blood vessels in those areas. At this point, we move into the hemostasis segment,
Segment:17 Focal Bladder Neck Cautery - Hemostasis.
5: which is key for optimizing hemostatic control and minimizing any subsequent complication, particularly of sexual functions.
5: So as mentioned, prepare prior to the completion of the second pass of the activation the resectoscope into syringe. Irrigate the bladder and remove all clots, and then insert the resectoscope. The key here is starting at the bladder neck and focusing on the significant blood vessels in that area. Remove the fluffy tissue, be it mechanically or using the TURP electrocautery loop, and then using cautery specifically of those significant vessels.
5: So here, the surgeon is starting and looking at the floor of the bladder neck not to encroach further back toward the apex or midsection and simply removing the tissues around that bladder neck to uncover the more familiar bladder neck fibers, and thereby localizing the one or two significant arterial vessels that would be the source of that bleeding.
5: So then, again, using selective cautery at the bladder neck to ensure optimal hemostasis prior to catheter insertion. So here after resecting, no more do we see the fluffy tissues but the typical bladder fibers we would normally see during a standard TURP. Occasionally, due to large amounts of anterior tissue, the surgeon may also deem it necessary to do anterior resection of the prostatic urethra for significant adenoma in that area.
5: Again, taking the time necessary during these 5 or 10 minutes are important to ensuring a smooth post-op recovery for these patients. Here, you can see a significant vessel cauterized taking the time necessary in the bladder neck cautery, which is the source of most significant blood bleeding after TUR resections.
5: Use of a continuous sheath is also suggested so as to minimize bladder overdistension and the need for repetitive unlocking, removal of the full bladder, and then repeating. So a continuous resectoscope sheath is highly recommended.
5: As mentioned, search for the fluffy tissues at the bladder neck. Use the loop to remove that fluffy irregular tissue post-op aquablation. And then, use the cautery selectively to cauterize those significant arterial bleeding sources. This is usually done several times, ensuring that the significant blood vessels or cauterize so as to allow for shorter hospitalization and shorter catheter timing.
5: So the efflux should be a light pink by the end of the procedure. Otherwise, suggestion to the surgeon is to continue repeating until all blood vessels are controlled.
Segment:18 Post Operative Care.
5: Post-operative care. Once the aquablation therapy and the hemostasis are complete, a three-way hematuria catheter should be placed, where the balloon is filled to 30 or 60 ccs in the balloon and that continuous bladder irrigation is commenced.
5: Commonly used catheters include the Rusch, 22 French, 24 French, or the BARD system. There's also the 24 French Coloplast x Flo. Suggestion is at the discretion of the treating surgeon and their comfort. The catheter is then secured with variable traction, either to leg or wet gauze synced against to ensure crystal clear urine to light red at the end of the procedure for the irrigation.
5: Some physicians will use a BNO suppository, Belladonna and Opioid, to help ensure that the patient have comfort with the catheter position and improve patient compliance and comfort. The patients is then admitted to the PACU for up to 3 to 4 hours of continuous bladder irrigation and monitoring by the nursing team. It is important to continue to monitor blood pressure and patient comfort and their BP medications prior to the procedure.
5:
Segment:19 Potential for Same Day Discharge.
5: Potential for same day discharge. Key opinion leaders have previously reported a white paper on this topic. But after the 4 hours of CBI, the decision algorithm is used as outlined on the right. If the degree of hematuria is not clinically significant, either a grade I, II, or III, as seen on the bottom right, in the red, 10 minutes after clapping the irrigation, the patients can be discharged home.
5: For those patients with a grade IV or grade v, significant bleed observation after being admitted is necessary, and the potential for returning back to the operating room should be considered by the treating surgeon.
Segment:20 Clinical Outcomes.
5: From the clinical outcomes, we know from the WATER I, the randomized controlled trial versus TURP, with now five year outcomes, the surgical retreatment rate is 5% and the medical retreatment rate is only 1%.
5: IPSS improvements dropped by 15 points, a 69% reduction, similar to the quality of life improvements and with a dramatic 125% greater q-max compared to baseline. What was very impressive is the low ejaculatory dysfunction rate notably from the butterfly cuts and anatomic respect for the apical tissues. Note, no patient had any reported erectile dysfunction or incontinence.
5: For the WATER II trial, for the single arm, four year now outcomes of men with prostates, over 80 grams up to 150 grams, note the surgical retreatment rate of only 3%, the medical BPH treatment rate of 6%, and very similar improvements both in IPSS, quality of life, and q-max urinary flow. Ejaculatory function was a little bit higher at 15%. Still, notably improved compared to the counterparts of hold up, TURP, or green light laser with much higher ejaculatory dysfunction rates, and again, very respectable low to non-existent erectile dysfunction or incontinence Thank you.
5:
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