Transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia

Evidence-based recommendations on transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia in adults. This involves injecting a high-speed jet of water into the prostate to destroy some of the tissue.

# Recommendations
The evidence on transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia raises no major safety concerns. The evidence on efficacy is limited in quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wishing to do transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia should:
Inform the clinical governance leads in their NHS trusts.
Ensure that patients understand the uncertainty about the procedure's efficacy and provide them with clear written information to support shared decision-making. In addition, the use of NICE's information for the public on transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia is recommended.
Audit and review clinical outcomes of all patients having transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia. NICE has identified relevant audit criteria and has developed NICE's interventional procedure outcomes audit tool (which is for use at local discretion).
The procedure should only be done by clinicians who have been trained in the technique.
NICE encourages further research into transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia and may update the guidance on publication of further evidence. Further research should report long-term followup and include reintervention rates.# The condition, current treatments and procedure

# The condition
Benign prostatic hyperplasia is a common condition that affects older men. Stromal and epithelial cells increase in number, causing the prostate to get bigger. It often happens in the periurethral region of the prostate, with large discrete nodules compressing the urethra. Symptoms include hesitancy during urination, interrupted or decreased urine stream (volume and flow rate), nocturia, incomplete voiding and urinary retention.

# Current treatments
Mild symptoms are usually managed conservatively. Drugs may also be used, such as alpha blockers and 5alpha-reductase inhibitors. If other treatments have not worked, there are a range of surgical options that may be considered. These include transurethral resection of the prostate, transurethral vaporisation, holmium laser enucleation, insertion of prostatic urethral lift implants, prostate artery embolisation or prostatectomy (see NICE's clinical guideline on lower urinary tract symptoms in men). Potential complications of some of these procedures include bleeding, infection, urethral strictures, incontinence and sexual dysfunction.

# The procedure
Transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia uses a specialised system that combines image guidance and robotics for the targeted heat-free removal of prostate tissue. The procedure is usually done with the patient under general or spinal anaesthesia. Transrectal ultrasound is used throughout the procedure. A handpiece with an integrated cystoscope and ablation probe is inserted through the urethra and into the bladder. Positioning is confirmed by using visual markers on a computer screen, and the surgeon is able to plan the depth and angle of resection using the system software. Once the surgical mapping is complete, a high-speed jet of saline is delivered to the prostate at various flow rates, according to the depth of penetration needed. The ablated tissue is aspirated through ports in the handpiece and can be used for histological analysis. Haemostasis can be achieved by cautery or by inflating a Foley balloon catheter inside the prostatic cavity. The average resection time is typically about 3 to 5 minutes. After the procedure, a 3way Foley catheter is placed under traction and continuous bladder irrigation is started. Traction is removed a few hours after the procedure and irrigation is progressively decreased. The catheter is removed before the patient is discharged from hospital, usually the day after the procedure.
The possible advantages of the procedure include a reduction in resection time compared with other endoscopic methods, and the potential to preserve sexual function. The procedure is heat-free, which removes the risk of complications arising from thermal injury.