A treatment aimed at preserving continence and sexual function after surgery
Benign prostatic hyperplasia (enlarged prostate) can affect quality of life in middle-aged and older men, and can lead to more serious complications if it progresses, which is why early treatment is generally advised. It is estimated that around 1.08 million men in Japan live with the condition, and any man over 50 can develop it; some degree of symptomatic enlargement is reported in roughly 6% of men in their sixties and 12% of men in their seventies. This hospital began offering Aquablation, a newer treatment for enlarged prostate, in July 2024, the sixth institution in Japan to introduce it. We spoke with Dr. Daiki Kato, of our urology department, about how the procedure works.
About the physician
Dr. Kato graduated from Hamamatsu University School of Medicine in 2009 and completed graduate study at Nagoya City University in 2020, training at university hospitals, regional core hospitals, and a children's hospital. His subspecialties are benign prostatic hyperplasia and pediatric urology, with a particular focus on treatment that supports quality of life in later years. He has performed transurethral resection of the prostate, transurethral holmium laser enucleation, and transurethral vaporisation of the prostate, and has worked with transurethral prostate lift and transurethral water vapour therapy, both newly introduced in Japan from 2022, presenting on these procedures at conferences and in published research.
What is Aquablation therapy?
Aquablation received insurance coverage in Japan in 2023. A rectal ultrasound probe monitors the prostate while a robotic system removes the enlarged tissue using a high-pressure water jet. The physician marks out the area to be removed on a monitor, and the robotic system carries out the resection under that instruction, which keeps technique consistent rather than dependent on any one surgeon's hand. The resection itself typically takes five to ten minutes regardless of prostate size, and the whole procedure, including recovery from anaesthesia, is usually complete within about an hour.
What is benign prostatic hyperplasia?
The condition occurs when an enlarged prostate compresses the urethra. A healthy prostate is roughly the size of a small strawberry, but can grow to the size of a kiwi fruit if left untreated. The most common complaint, and the one that most affects daily life, is frequent urination; needing to urinate one or more times overnight is called nocturia. Research has associated needing to get up twice or more a night with roughly double the mortality risk, and it can also contribute to falls and daytime sleepiness. A weak stream, difficulty starting urination, or straining to urinate can also point to this condition. In practice, diagnosis draws on a symptom questionnaire, ultrasound measurement of prostate size, and a flow-rate test, weighing overall severity to decide on treatment.
How is it treated?
Treatment usually begins with medication. The most commonly prescribed are alpha-1 blockers, which relax the muscle at the neck of the bladder and prostate to ease symptoms; around six types with differing pharmacological effects are available today, and the type and dose can be adjusted as symptoms are reviewed. Where medication is not enough, or complications arise, surgery may be considered. Beyond Aquablation, this hospital also offers transurethral water vapour therapy (Rezum), which uses steam to destroy enlarged tissue, and transurethral prostate lift (Urolift), which uses implants to hold the prostate open. Both carry a low bleeding risk and can be performed even for patients on blood-thinning medication.
How does Aquablation differ from earlier surgery?
The two biggest differences from earlier surgical approaches are that a robotic system, rather than a surgeon's hand, removes the tissue, and that it is removed using water. Earlier procedures used an endoscope inserted through the urethra, with an electric cautery device or laser used by hand to remove the enlarged tissue, typically taking one to one and a half hours depending on prostate size, and requiring extensive individual surgical experience to perform well. With Aquablation, a robotic system performs the resection; the surgeon simply marks the area to be removed while viewing the prostate by ultrasound, so outcomes depend less on individual surgical skill, and resection itself takes only about five to ten minutes.
Availability in Japan
Aquablation was first introduced in Europe in 2017 and is now used in more than twenty countries, with roughly five hundred systems worldwide and about sixty thousand procedures performed to date. It received Japanese insurance coverage in June 2023, and as of July 2024 this hospital is one of six institutions in Japan offering it. Unlike many larger hospitals, this hospital does not require a referral letter to be seen, and surgery does not require a wait of several months.
Other advantages
Because the procedure uses high-pressure water rather than heat from an electric cautery or laser, it substantially reduces the thermal damage to surrounding nerves and muscle that can contribute to post-operative incontinence or erectile difficulty. Because the exit of the ejaculatory duct running through the prostate is not removed, ejaculatory function can also be expected to be preserved. Very few institutions in Japan currently offer this procedure.
Recovery
The urinary catheter is typically removed on the second day after surgery, with discharge on day three if there are no complications. Walking and eating are possible from the day after surgery, but strenuous exercise and alcohol should be avoided for a while after discharge, and cycling and similar activity that puts pressure on the prostate should be avoided for about a month.
A closing note
Benign prostatic hyperplasia has a significant effect on daily life, yet many people assume it is simply an unavoidable part of ageing. A routine health checkup will not tell you the size of your prostate or whether a urinary condition is present. We hope more people come to know that this can often be addressed with an approach that places relatively little burden on the body. No referral letter is required, and we can typically arrange surgery within one to two months of a booking. Please feel free to talk to us if this is a concern for you.
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