Transurethral Waterjet Ablation of the Prostate

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Transurethral Waterjet Ablation of the Prostate. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Transurethral Waterjet Ablation of the Prostate and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

• CMS IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 14, §10 Coverage of Medical Devices
• CMS IOM, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, §30 Services paid under the Medicare Physicians Fee Schedule
• CMS IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
• Title XVIII of the Social Security Act, § 1862(a)(7). This section excludes routine physical examinations.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Benign prostatic hyperplasia (BPH) is a histological diagnosis characterized by an increased number of epithelial and stromal cells in the prostate. It is common in men over the age of 40, and the incidence increases with age. In the United States, 8 million men older than 50 years old suffer from BPH. In many cases BPH is asymptomatic, however, symptoms may occur with prostate enlargement and compression of the urethra leading to bothersome lower urinary tract symptoms (LUTS), including voiding symptoms such as hesitancy, weak stream, straining, prolonged voiding, and storage symptoms (frequency, urgency, and nocturia). LUTS/BPH can have a significant impact on the quality of life and can cause serious complications such as infections, bleeding, calculus formation, urinary retention and decline of renal function when untreated.¹ First line treatment generally consists of treatment with medications such as alpha blockers, PDE5 Inhibitors, or finasteride/dutasteride. If treatment with medications is not successful, surgical options may then be considered. Transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) are the standard surgical treatments for LUTS/BPH and are highly effective and provide improved outcomes in urinary functions. However, neither TURP nor OSP are without considerable perioperative complication and morbidity.² Recently, new minimally invasive surgeries have emerged as alternatives for the resection of the prostate to manage LUTS in men with BPH. One such surgery is transurethral waterjet ablation which is minimally invasive; water based surgical therapy that combines image
guidance and robotics to remove prostatic tissue.³ The system works by pumping high pressure saline (500 to 8000 pounds per square [PSI]) through a probe nozzle to cut and dissect tissue at predetermined system parameters.³

Covered Indications
Treatment for LUTS/BPH will be considered reasonable and necessary ONCE per lifetime in patients with:

1. All of the following indications:
   1. Prostate volume of 30-150ml^4,5
   2. Persistent moderate to severe symptoms despite maximal medical management including ALL of the following:
      1. International Prostate Symptom Score (IPSS) ≥12⁴
      2. Maximum urinary flow rate (Qmax) of ≤15 mL/s^4,5
      3. Failure, contraindication or intolerance to at least 3 months of conventional medical therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)
2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary.

Limitations
Transurethral waterjet ablation of the prostate is not considered reasonable and necessary for patients with the following:

1. Body mass index ≥ 42kg/m2⁶
2. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines⁷) or a prostate specific antigen (PSA) >10 ng/mL unless the patient has had a negative prostate biopsy within the last 6 months.
3. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum⁶
4. Active urinary tract or systemic infection⁶
5. Treatment for chronic prostatitis⁶
6. Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture⁶
7. Damaged external urinary sphincter⁶
8. Known allergy to device materials⁸
9. Inability to safely stop anticoagulants or antiplatelet agents preoperatively.⁸

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

Year 1, Year 2 and Year 3 Outcomes
Initial clinical experience was reported in 2016, and the technology obtained FDA clearance in 2017 after the publication of the WATER trial, a PHASE III multicenter international, double blind, randomized, non-inferiority study with 181 subjects comparing Aquablation^® (116/181) to TURP (65/181).⁹ Men 45-80 years old with prostate size 30-80 cc (by TRUS), moderate-severe LUTS (International Prostate Symptom Score (IPSS) ≥ 12), and maximum urinary flow rate (Qmax) <15ml/s were included and stringent exclusion criteria applied. Although treatment was by an unblinded research team after randomization, a separate blinded team performed all follow-up. The primary endpoint was the change in the IPSS at 6 months; scores decreased by 16.9 points and 15.1 points for Aquablation^® and TURP, respectively (noninferiority p<.0001 and superiority p=0.1347). The primary safety endpoint was the proportion of subjects with adverse events, defined as Clavien-Dindo grade 2 or higher or any grade 1 with persistent disability. The 3-month primary safety endpoint rate was lower in the Aquablation^® group than in the TURP group (26% vs 42%, p = 0.0149). At 2 years, IPSS score improvement was sustained (14.7 in Aquablation^® and 14.9 in TURP (p=0.834, 95% CI for difference -2.1 to 2.6)), and Qmax improvement was large in both groups (11.2 and 8.6 cc/s for Aquablation^® and TURP, respectively (p = 0.1880, 95% CI for difference -1.3 to 6.4).¹⁰ Two-year reduction in post-void residual (PVR) was 57 and 70 cc for Aquablation^® and TURP, respectively (p = 0.3895). Prostate specific antigen (PSA) decreased significantly in both groups by 1 point (p < 0.01). Retreatment rates were 4.3% and 1.5% (p = 0.42) in the Aquablation^® and TURP groups, respectively. Among the subset of sexually active men without the condition at baseline, anejaculation was less common after Aquablation^® (10% vs. 36%, p=0.0003). When post-Aquablation^® cautery was avoided rates of anejaculation were lower (7% vs. 16%, p=0.1774), and this resulted in the reduced grade 1 persistent events found in the Aquablation^® group. The authors hypothesize that Aquablation^® avoids damage to tissues involved in ejaculation though precise, image-based targeting, and robotic execution. Limitations of the study include the risk of performance bias as surgeons were not blinded, and unknown generalizability to a broader population. Three-year results were essentially unchanged.⁴

Gilling PJ et al. (2022) published the 5-year follow-up data for the WATER study.²⁰ Five-year follow-up revealed IPSS scores improved by 15.1 points in the Aquablation^® group and 13.2 points in TURP (p = 0.2764). IPSS reduction was 3.5 points greater across all follow-up visits in the Aquablation^® group compared to the TURP group (p = 0.0123) for men with larger prostates (≥50mL). Peak urinary flow rates for Aquablation^® and TURP improved when compared to baseline (125% and 89% respectively). 12.3% of patients treated with TURP required a subsequent intervention compared to 6% of patients treated with Aquablation^®, up to 5 years secondary to recurrent LUTS.

A 2019 Cochrane Review based on 1-year WATER trial results, found evidence of similar results with TURP to be of moderate-certainty related to the urologic symptom score (IPSS) primary outcome measure. All other metrics were graded low-certainty (QOL), to very low-certainly (adverse events, retreatments, erectile function, ejaculatory dysfunction).³ Evidence was downgraded mainly due to study limitations (performance, reporting, and attrition bias), and imprecision (confidence intervals that crossed the assumed thresholds of clinically important differences or few events, or both). For example, both sexual outcome (erectile and ejaculatory function) results were downgraded 2 levels for a combination of imprecision and study limitations (high risk of performance and attrition bias). The authors recommend larger, more rigorously conducted, and transparently reported, studies comparing Aquablation^® to other techniques (laser enucleation, prostatic urethral lift, robotic-assisted simple prostatectomy) for which there is also increasing interest.

In a study by Nguyen DD, Barber N, Bidair M et al.⁶ The authors looked to determine if the effectiveness of Aquablation^® is independent of prostate size by comparing its outcomes in 2 clinical trials. The first trial that was conducted was with men whose prostate was between 30 and 80 mL (WATER I) and the other trial was conducted with men whose prostates were between 80 and 150 mL (WATER II). Water I trial is a prospective, double-blind, multicenter, international clinical trial comparing the safety and ef?cacy of Aquablation^® and TURP as surgical treatments of LUTS due to BPH in men aged 45–80 years with a prostate volume between 30 and 80 mL, as measured by TRUS. Patients were enrolled at 17 centers. One hundred sixteen men participated. The Water II trial was a prospective, multicenter, international clinical trial of Aquablation^® for the surgical treatment of LUTS/BPH in men aged 45–80 years with a prostate volume between 80 and 150 mL, as measured by TRUS. Patients were enrolled at 13 US and 3 Canadian sites. One hundred one men participated. The studies parameters included patients who completed the IPSS. Patients completed questionnaires such as the Incontinence Severity Index (ISI), the International Index of Erectile Function (IIEF-5), and the Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EjD). Patients received uro?owmetry, PVR measurements and underwent standard laboratory blood assessment. These questionnaires and measurements were provided at baseline. PVR and lab test were required postoperatively at 1 and 3 months. Adverse events were rated by the clinical events committee as possible, probably or definitely related to the study procedure and were classified using Clavien–Dindo grade for 3 months after treatment. The inclusion and exclusion criteria were the same for both studies. The inclusion criteria included patients with moderate-to severe symptoms indicated by a baseline IPSS of ≥12 and a maximum urinary flow rate (Qmax) of <15 mL/s. Exclusion criteria included patients with a body mass index of ≥42 kg/m², a history of prostate or bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum, active infection, treatment for chronic prostatitis, diagnosis of urethral stricture, meatal stenosis or bladder neck contracture, a damaged external urinary sphincter, stress urinary incontinence, post-void residual urine volume (PVR) >300 mL or urinary retention. The comparison between the 2 studies revealed the mean operative time for WATER I was 33 minutes and 37 minutes for WATER II. The actual treatment time was 4 minutes (WATER I) and 8 minutes (WATER II). For International Prostate Symptom Score, the mean change at 12 months averaged 15.1 for WATER I and 17.1 for WATER II (P = 0.605). Clavien–Dindo grade ≥II events at 3 months mark occurred in 19.8% of WATER I patients and 34.7% of WATER II patients (P = 0.468).⁶ The authors conclude outcomes and effectiveness of Aquablation^® are comparable and are independent of prostate size with the expectation that with larger prostates a higher risk of complication is possible.

In an April 2020 publication of WATER II data in the Canadian J Urol, Desai et. al.⁵ report, 2-year safety and effectiveness of the Aquablation^® procedure for treatment with men with symptomatic benign prostatic hyperplasia (BPH) and large volume 80-150 cc prostates. The study provides strong evidence that Aquablation^® provides excellent mid-term (2 year) long-term relief of LUTS related to BPH. The study is notable in that enrolled men (target range 80-150 cc, mean 107 cc, 83% with a large median lobe), a group that typically cannot undergo TURP were included.

Bach et al (2020) conducted a prospective, multicenter, single-arm, open-label clinical trial (OPEN WATER) of Aquablation^® therapy in 5 community-based sites.²¹ The study included 178 men with the diagnosis of LUTS/BPH, aged 38–88 years with a prostate volume between 20 and 148 mL, as measured by TRUS. At baseline and at 3- and 12-month follow-up, patients completed the following: IPSS, Incontinence Severity Index, Pain Intensity Scale, Quality of Recovery Visual Analog Scale, International Index of Erectile Function (IIEF-15), the Male Sexual Health Questionnaire (MSHQ-EjD), uroflowmetry, and post-void residual (PVR) volume measurements. The IPSS decreased from 21.7 at baseline to 6.4 at the 12-month follow-up (p < 0.0001). The maximum urinary flow rate increased from 9.9 mL/s at baseline to 20.8 mL/s at month 12 (p < 0.0001). PVR improved from 108 mL to 47 mL at 3 months and 61 mL at 12 months. Ejaculatory function was relatively preserved. Prostate volume assessed with transrectal ultrasound decreased 36% by month 3. The authors concluded that “real-world” evidence (patients in a non-clinical trial setting) shows that the Aquablation^® procedure is safe and effective for the treatment of symptomatic BPH.

A retrospective review of prospectively collected data by Kasraeian et al (2020) evaluated the safety and efficacy of Aquablation^® in a community-based setting.²² The study included 55 patients treated between July 2018 and December 2019 with prostate size ranging from 27 to 252 mL in volume (mean of 100 mL). Patient ages ranged from 50 to 84 years. Results demonstrated a significant improvement in the mean IPSS of 17.2 points (p < 0.0001). By uroflowmetry, the mean Qmax improved from 7.4 mL/sec at baseline to 20.6 mL/sec postoperatively (p < 0.0001). Patients with prostate volume >100 mL had similar hospital length of stay, BPH symptom reduction, and Qmax improvement compared to patients with prostate volume <100 mL.

American Urological Association (AUA) amended guidelines now include Aquablation^®, but do not classify it as a minimally invasive surgical treatment (MIST) since general anesthesia is required. Based on 1-year WATER study results the AUA, found parity between Aquablation^® and TURP on IPSS, LUTS, and QOL scores (Quality of Evidence: Moderate). Their recommendation is: “Aquablation^® may be offered to patients with LUTS attributed to BPH provided prostate volume >30/<80g; however, patients should be informed that long term evidence of efficacy and retreatment rates remains limited. (Conditional Recommendation; Evidence Level: Grade C)”.¹¹

Canadian Urological Association (CUA) 2018 guidelines also give a “conditional recommendation based on moderate-quality evidence” that Aquablation^® may be offered to men “interested in preserving ejaculatory function, with prostates <80 cc, with or without a middle lobe”.¹²

A 2018 National Institute for Health and Care Excellence (NICE) systematic review based on 6-month WATER results concluded the procedure should only be used with “special arrangements,” a defined designation meaning there are uncertainties about safety and effectiveness.¹³

PubMed and Google Scholar were searched for peer-reviewed, evidence-based literature providing information on the analytic and clinical validity and clinical utility of transrectal ultrasound (TRUS) and Magnetic Resonance Imaging (MRI). Keywords used in the search were transrectal ultrasound and prostate and MRI and prostate volume.

A total of 2 publications, observational studies of retrospective nature, addressed the analytical validity of MRI and TRUS for prostate volume measurement.^23,24 Studies excluded from analysis included systematic reviews with a low certainty of evidence,^25,26 studies focusing on Prostate-Specific Antigen Density (PSAD)²⁷ and studies addressing the clinical utility of MRI-targeted biopsy,²⁸ which is beyond the scope of this policy.

Bezinque et al retrospectively reviewed records of 99 patients who underwent radical prostatectomy within 1 year of multiparametric prostate MRI (mpMRI) to determine optimal prostate volume (PV) measurement techniques.²³ The reference used was manual segmentation by a radiologist (MRI-R3D). MRI based methods were found to be the most reliable, with stronger intra-class correlation coefficients of .91 for manual segmentation by a third-year medical student (MRI-S3D) and .90 for MRI-ellipsoid formula. Digital rectal examinations (DRE) were the least reliable (.33). Although transrectal ultrasound (TRUS) yielded less favorable results (.71), it remains a useful tool for PV measurement as it is reliable, reasonably accurate, and commonly used when mpMRI is not performed.²³

In addition to the retrospective nature of this study, the authors have noted several limitations. These include small sample size, the failure to use surgical specimens as a reference standard, which may have provided more accurate PV measurements, and lack standardization between participating institutions. Therefore, interobserver variation could not be assessed, as a single radiologist performed the reference measurements, and a single urologist determined DRE and TRUS measurements. Other studies have shown low interobserver variability for MRI in PV assessments, thereby minimizing concern for MRI-R3D as the reference standard. The outcomes may have been affected by changes in prostate sizes within 1 year of mpMRI, as well as the absence of CT segmentation data for PV to compare with other methods. Due to the average younger age of 63 years (range of 59-68) and undergoing radical prostatectomy in the study cohort, results also may not be fully generalized to the Medicare population, and outcomes may have differed for those older or without prostate cancer.²³

Analytical validity was assessed by Weiss et al in a retrospective comparison of preoperative transrectal ultrasound (TRUS) versus endorectal MRI (eMRI) in 756 patients diagnosed and treated for localized prostate cancer. A high correlation was found between the 2 methods in estimating prostate volume using the prolate ellipsoid formula. There was a significant correlation for average prostate size measured (R=.801; P < .001), as well as a strong linear relationship. The average difference in measurement in TRUS relative to eMRI was 1.7 mL, showing statistical significance (P < .001), without clinical relevance. These conclusions support the use of TRUS for prostate volume measurement in patients with prostatic disease due to its accuracy, reproducibility, and efficacy, despite the superiority of MRI based estimation of prostate size.²⁴

Peer-reviewed literature focused on providing information on the safety and effectiveness of performing transurethral waterjet ablation of the prostate in patients with Q_max ≤15 mL/s (voided volume greater than 125 cc) was sought and analyzed. Four publications were identified which addressed the safety of performing transurethral waterjet ablation of the prostate in patients with retention abilities and showed the effectiveness of the procedure on Q_max. Additionally, the WATER II trial, which has been mentioned in previous sections, included cohorts of catheter-dependent patients who could not pass meaningful amounts of urine, and therefore could not undergo a flow rate test that requires 125 cc of volume voided. This cohort of catheter-dependent patients,²⁴ demonstrated benefit from undergoing the Aquablation procedure. AUA guidelines on the Management of LUTS Attributed to BPH, published in 2021, addressed the treatment of patients in urinary retention.¹⁵ The guideline states that indications for surgery include “a desire by the patient to avoid taking a daily medication, failure of medical therapy to sufficiently ameliorate bothersome LUTS, intolerable pharmaceutical side effects, and/or the following conditions resulting from BPH and for which medical therapy is insufficient: acute and/or chronic renal insufficiency, refractory urinary retention, recurrent urinary tract infections (UTIs), recurrent bladder stones, and recalcitrant gross hematuria.²⁹ The guideline identifies Robotic Waterjet Treatment (e.g., Aquablation) as a treatment option for patients with LUTS/BPH provided that the prostate volume ranges between 30-80 cc.²⁹

Additional peer-reviewed literature has demonstrated that Aquablation is clinically effective and safe in patients with catheter-dependent urinary retention. Burton et al compared outcomes of Aquablation in men with acute and chronic urinary retention.³⁰ This retrospective study of 113 men (69 not in retention, 28 with acute retention and 16 with chronic retention) found no difference in utilization of postoperative prostate medications, complications, IPSS, or uroflowmetry between men with acute, chronic, or no retention. There was no significant difference for men using intermittent catheterization as compared to those with an indwelling catheter prior to surgery in relation to the ability to return to spontaneous voiding faster (P = .31). The study found that 98% of participants achieved spontaneous voiding after Aquablation regardless of preoperative urodynamic status. Limitations of this study included small sample sizes for acute and chronic patients, preoperative urodynamics not routinely obtained for all patients, and the study’s retrospective nature.

A prospective observational study addressed a cohort of 60 men with significant BPH who underwent Aquablation at a single ambulatory surgery center.³¹ Results showed significant improvements in urinary flow rates and significant reductions in IPSS scores at 1 month post-operatively. The occurrence of pain post Aquablation procedure was infrequent and the incidence of postoperative complications, including urinary retention, was infrequent and in alignment with previously published outcomes. The mean 1-month Q_max increased to 26 mL/s and the mean PVR volume decreased to 39 mL. The authors noted several limitations that include a short follow-up time, a small sample size, performance in a single center study, and an accompanying selection bias.

Finally, a prospective observational study by Labban et al published in 2021,³² assessed 59 consecutive patients who underwent Aquablation at a tertiary care center. The study population included 14 patients in urinary retention. At the 3-month follow-up, significant drops in PSA score, prostate size, and IPSS (P < .001 for all) were observed. PVR volume was reduced significantly –186 ± 82 mL (P = .01). A sub-analysis among patients with retention at baseline revealed a similar operative time (P = .38), length of catheterization (P = .53), and length of hospital stay (P = .94) when compared to patients not in urinary retention. The study had limitations which included a small sample size and the lack of a control group. Despite these limitations, the results of this study echo the findings of other studies that confirmed improved voiding parameters and decreased LUTS.

Study limitations include its retrospective nature, the use of differing measurement methods, not estimating TRUS and eMRI volumes with the same units. The accuracy of imaging techniques was not verified with more precise methods such as planimetry-based estimations or anatomical specimens. Additionally, a notable limitation is that this study population consists of prostate cancer patients with a mean age of 59 years (interquartile range 9) which may not be generalizable to older Medicare populations that do not have prostate cancer.³¹

The body of peer-reviewed evidence does not support specific measurement techniques as superior or preferred for prostate volume determination. Although MRI is shown to be slightly more accurate, the certainty of evidence supports that TRUS provides comparable results and is a useful tool often recommended due to its reliability, especially when MRI is unavailable or contraindicated.^23,24 Therefore, TRUS is no longer the only imaging modality required to determine the prostate volume.

Overall, there is strong evidence to continue the use of Q_max as a measurement for urinary retention. Additionally, there is moderate evidence supporting the use of transurethral waterjet ablation for patients with urinary retention.^29,30-31 Based on the submitted and identified literature, it was determined that there is sufficient evidence to support removing the voided volume requirement from the covered indications. Consequently, the minimum 125 cc voided volume reference has been removed from the LCD.

In summary, promising short-term, single study, Aquablation^® results have resulted in, at best, conditional recommendations in some guidelines (AUA, CUA, NICE). However, a conditional recommendation with Grade C evidence level (AUA) which translates to “Balance between Benefits & Risks/Burdens unclear. Alternative strategies may be equally reasonable. Better evidence likely to change confidence.”, echoing the Cochrane Review recommendation: “any recommendation for or against the use of Aquablation^® would be based on only very low-certainty evidence.” However, these guideline recommendations predate publication of mid-term (3-year) results, which demonstrate persistent outcome with TURP.⁴ These studies and recommendations demonstrate the safety and effectiveness of Aquablation^® as an option for men aged equal to or less than 80, with moderate to severe LUTS due to benign prostate hyperplasia as indicated by International Prostate Symptom Score (IPSS) equal to or greater than 12 and a 30-80 cc prostate. Also, the ability to preserve sexual function is a major consideration. Further follow up reports 2-year safety and effectiveness of the Aquablation^® procedure for treatment with men with symptomatic benign prostatic hyperplasia (BPH) and large volume 80-150 cc prostates.

Therefore, based on the 2 and 3-year results, as well as recommendations from the AUA and CUA, water jet treatment of LUTS/BPH is considered to be medically reasonable and necessary when performed as outlined in this LCD.

Please refer to the related Billing and Coding: Transurethral Waterjet Ablation of the Prostate A58209 Article for documentation and utilization requirements as applicable

Contractor Medical Directors Waterjet Ablation Workgroup

1. Zorn KC, Goldenberg SL, Paterson R, So A, Elterman D, Bhojani N. Aquablation^® among novice users in Canada: A WATER II subpopulation analysis. J Can Urol Assoc 2019;13(5):E113-E118.
2. Chung ASJ, Woo HH. Update on minimally invasive surgery and benign prostatic hyperplasia. Asian J Urol. 2018;5(1):22-27.
3. Hwang_EC, Jung_JH, Borofsky_M, Kim_MH, Dahm_P. Aquablation^® of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database of Systematic Reviews 2019, Issue 2. Art. No.: CD013143.
4. Gilling P, Barber N, Bidair, M, et al. Three-year outcomes after Aquablation^® therapy compared to TURP: results from a blinded randomized trial. Can J Urol. February 2020; 27(1):10072-10079.
5. Desai M, Bidair M, Bhojani N et al. Aquablation^® for benign prostatic hyperplasia in large prostate (80-150 cc): 2-year results Can J Urol. 2020; 27(2): 10147-10153.
6. Nguyen DD, Barber N, Bidair M, et al. Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30-80 and 80-150 mL prostates. BJU Int. 2020;125(1):112-122. doi:10.1111/bju.14917
7. Carroll PR, Parsons JK, Andriole G, et al. NCCN Guidelines Insights: Prostate Cancer Early Detection, Version 2.2016. J Natl Compr Canc Netw. 2016;14(5):509-519. doi:10.6004/jnccn.2016.0060
8. FDA Approval: De Novo Classification Request for AQUABEAM System. Accessed 7/2/19]
9. Gilling P, Barber N, Bidair M, et al. Randomized Controlled Trial of Aquablation^® versus Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia: One-year Outcomes. Urol. 2019;125:169-173
10. Gilling P, Barber N, Bidair M, et al. Two-Year Outcomes After Aquablation Compared to TURP: Efficacy and Ejaculatory Improvements Sustained. Adv Ther. 2019;36(6):1326-1336. doi:10.1007/s12325-019-00952-3
11. AUA Guidelines: Benign Prostatic Hyperplasia: Surgical Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms (2018, amended 2019, amended 2020). 2020
12. Nickel JC, Aaron L, Barkin J, Elterman D, Nachabe M, Zorn KC. Canadian Urological Association guideline on male lower urinary tract symptoms /benignprostatic hyperplasia (MLUTS/BPH): 2018 update. Can Urol Assoc J. 2018; 12:303-312.
13. Overview: Transurethral water-jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia: Guidance. NICE. Accessed August 23, 2024. https://www.nice.org.uk/guidance/ipg770.
14. Taktak S, Jones P, Haq A, Rai BP, Somani BK. Aquablation: a novel and minimally invasive surgery for benign prostate enlargement. Ther Adv Urol. 2018;10(6):183-188. Published 2018 Feb 26. doi:10.1177/1756287218760518
15. Desai M, Bidair M, Bhojani N, et al. WATER II (80-150 mL) procedural outcomes. BJU Int. 2019;123(1):106-112. doi:10.1111/bju.14360
16. Sturch P, Woo HH, McNicholas T, Muir G. Ejaculatory dysfunction after treatment for lower urinary tract symptoms: retrograde ejaculation or retrograde thinking? BJU Int. 2015;115(2):186-187.
17. Bhojani N, Bidair M, Zorn KC, et al. Aquablation for Benign Prostatic Hyperplasia in Large Prostates (80-150 cc): 1-Year Results. Urology. 2019;129:1-7. doi:10.1016/j.urology.2019.04.029
18. Misrai V, Rijo E, Zorn KC, Barry-Delongchamps N, Descazeaud A. Waterjet Ablation Therapy for Treating Benign Prostatic Obstruction in Patients with Small- to Medium-size Glands: 12-month Results of the First French Aquablation Clinical Registry. Eur Urol. 2019;76(5):667-675. doi:10.1016/j.eururo.2019.06.024
19. Kasivisvanathan V, Hussain M. Aquablation versus transurethral resection of the prostate: 1 year United States - cohort outcomes. Can J Urol. 2018;25(3):9317-9322.
20. Gilling PJ, Barber N, Bidair M, et al. Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol. 2022;29(1):10960-10968.
21. Bach T, Gilling P, El Hajj A, Anderson P, Barber N. First Multi-Center All-Comers Study for the Aquablation Procedure. J Clin Med. 2020;9(2):603. Published 2020 Feb 24. doi:10.3390/jcm9020603
22. Kasraeian A, Alcantara M, Alcantara KM, Altamirando JA, Kasraeian A. Aquablation for BPH. Can J Urol. 2020;27(5):10378-10381.
23. Bezinque A, Moriarity A, Farrell C, Peabody H, Noyes SL, Lane BR. Determination of Prostate Volume: A Comparison of Contemporary Methods. Acad Radiol. Dec 2018;25(12):1582-1587. doi:10.1016/j.acra.2018.03.014.
24. Weiss BE, Wein AJ, Malkowicz SB, Guzzo TJ. Comparison of prostate volume measured by transrectal ultrasound and magnetic resonance imaging: is transrectal ultrasound suitable to determine which patients should undergo active surveillance? Urol Oncol. Nov 2013;31(8):1436-40. doi:10.1016/j.urolonc.2012.03.002
25. Christie DRH, Sharpley CF. How Accurately Can Prostate Gland Imaging Measure the Prostate Gland Volume? Results of a Systematic Review. Prostate Cancer. 2019;2019:6932572. doi:10.1155/2019/6932572.
26. Wang S, Kozarek J, Russell R, et al. Diagnostic Performance of Prostate-specific Antigen Density for Detecting Clinically Significant Prostate Cancer in the Era of Magnetic Resonance Imaging: A Systematic Review and Meta-analysis. Eur Urol Oncol. Apr 2024;7(2):189-203. doi:10.1016/j.euo.2023.08.002.
27. Choe S, Patel HD, Lanzotti N, et al. MRI vs Transrectal Ultrasound to Estimate Prostate Volume and PSAD: Impact on Prostate Cancer Detection. Urology. Jan 2023;171:172-178. doi:10.1016/j.urology.2022.09.007
28. Hugosson J, Godtman RA, Wallstrom J, et al. Results after Four Years of Screening for Prostate Cancer with PSA and MRI. N Engl J Med. 2024;39(12):1083-1095. doi:10.1056/NEJMoa2406050.
29. Lerner LB, McVary KT, Barry MJ, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment. J Urol. Oct 2021;206(4):818-826. doi:10.1097/JU.0000000000002184.
30. Burton CS, Dobberfuhl AD, Comiter CV. Outcomes of Aquablation in Men With Acute and Chronic Urinary Retention. Urology. Oct 2023;180:214-218. doi:10.1016/j.urology.2023.06.028.
31. Zorn KC, Chakraborty A, Chughtai B, et al. Safety and Efficacy of Same Day Discharge for Men Undergoing Contemporary Robotic-assisted Aquablation Prostate Surgery in an Ambulatory Surgery Center Setting-First Global Experience. Urology. Aug 17 2024;doi:10.1016/j.urology.2024.08.006
32. Labban M, Mansour M, Abdallah N, et al. Aquablation for benign prostatic obstruction: Single center technique evolution and experience. Investig Clin Urol. Mar 2021;62(2):210-216. doi:10.4111/icu.20200249.
33. Hilscher M, Roder A, Helgstrand JT, et al. Risk of prostate cancer and death after benign transurethral resection of the prostate-A 20-year population-based analysis. Cancer. Oct 2022;128(20):3674-3680. doi:10.1002/cncr.34407.
34. Gilling P, Barber N, Bidair M, et al. WATER: A Double-Blind, Randomized, Controlled Trial of Aquablation((R)) vs Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia. J Urol. May 2018;199(5):1252-1261. doi:10.1016/j.juro.2017.12.065.
35. Tech, Jeremy Yuen Chun et al. “Robotic Waterjet Resection for Men with Prostate Cancer Suffering from Lower Urinary Tract Symptoms.” Urology, S0090-4295(25)00034-2. 14 Jan 2025. Doi:10.1016/j.urology.2025.01.020.
36. Chapelle C, Lavallee E, Vallee M, Descazeaud A. Bicentric retrospective study comparing the postoperative outcomes of patients treated surgically for bladder stones with or without concomitant surgery for BPH. World J Urol. Jan 8 2024;42(1):13. doi:10.1007/s00345-023-04699-z.

• BPH
• Aquablation
• Aquabeam
• TURP
• Fluid Jet