Surgeon: Vincent Misrai

Moderator: Christopher Netsch

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Vincent Misrai, M.D.

Vincent Misrai is Urologist based at Clinique Pasteur, Toulouse, France. He is specialized in the treatment of benign prostatic obstruction, including use of the greenlight laser. He runs a number of training courses in France and Europe teaching greenlight vaporization, endoscopic enucleation and Aquablation surgeries, and has been invited to operate and lecture nationally and internationally. He has published and coauthored more than 100 articles including articles relating to the management of patients with BPH disease and patients under oral anticoagulants. He is actively involved in the French Association of Urology LUTS committee and the European School of Urology Technology (ESUT) in the BPH section. He was awarded in 2015 by the National Academy of Medicine for his work on greenlight laser.

Christopher Netsch, M.D.

Dr. Christopher Netsch studied medicine at the University of Mainz (DE) and graduated in 2005. He finished his doctoral thesis at the University of Mainz (DE) in 2006. His training in urology was conducted at the Inselspital Bern (CH), Städtisches Klinikum Karlsruhe (DE) and the Asklepios Hospital Barmbek (DE). After his board certification in 2011, Dr. Netsch became a staff member at the Department of Urology of the Asklepios Hospital Barmbek. Here, he also attended a 24-month fellowship on Endourology. He was qualified as a Fellow of the European Board of Urology (FEBU) in 2015. Dr. Netsch finished his habilitation thesis at the Semmelweis University, Budapest (HU) in 2017. Dr. Netsch is a member of the German Working Group in Endourology, the EAU section of Uro-Technology (ESUT) and a reviewer for numerous journals such as the Journal of Endourology, Journal of Urology and the World Journal of Urology. He is also a member of the Editorial Board of the World Journal of Urology. Dr. Netsch published over 85 PubMed listed, peer-reviewed journal articles, numerous book articles, published numerous abstracts, and hold lectures on national/international congresses. He was awarded with the Wolfgang Mauermayer and the Winfried Vahlensieck award of the German Society of Urology and the Hans Marberger award of the European Association of Urology. His scientific and clinical interests in urology are endourological topics: stone disease and minimally-invasive therapies for BPH.

 

Webinar Transcript

Dr. Amy Krambeck:

Hello. My name is Dr. Amy Krambeck and I am the host of today's event. We have an exciting presentation. It is on aquablation and it's hosted by Procept. The Endourology Society and Society of Urologic Robotic Surgeons have put together this CME event. Today is hosted by Procept BioRobotics and we appreciate their grant in supporting this educational activity. The purpose of this educational event is to provide our attendees an online program dedicated to surgical techniques in endourology and robotics. The target audience is physicians who specialize in endourology and robotics. And we have multiple objectives that are listed on this slide. You will get CME certification and we will let you know at the end of the broadcast how you do that.

Dr. Amy Krambeck:

Today we have, aquablation in the treatment of BPH. Our surgeon is Vincent Misrai. He is a urologist based at Clinique Pasteur in Toulouse, France. He is specialized in the treatment of benign prostatic obstruction, including use of the greenlight laser. He is actively involved in the French Association of Urology LUTS committee and the European School of Urology Technology in the BPH section. He was awarded in 2015 by the National Academy of Medicine for his work on greenlight laser.

Dr. Amy Krambeck:

Our moderator is Christopher Netsch. Dr. Netsch did a two-year endourology fellowship and is a staff member at the Department of Urology of the Asklepios Hospital Barmbek. Dr. Netsch is a member of the German Working Group in Endourology, the EAU section of the Uro-Technology and is a reviewer for numerous journals such as the Journal of Endourology. His scientific and clinical interests in urology are endourological topics such as stone disease and minimally-invasive therapies for BPH. So I'm very excited to see these talks today and I'm going to turn the platform over to Dr. Netsch.

Dr. Christopher Netsch:

Yeah. Good evening to everyone. So Dr. Misrai will have the presentation on the AquaBeam procedure. He was the first author of the France AquaBeam study that was published in last year in the European Urology Journal. So I hope he will guide through the AquaBeam topic very well and I hope he will give us new insights into this very new technology. And I think he will start now. Dr. Misrai.

Dr. Vincent Misrai:

Yeah. Hello everybody. I'm really delighted to share with you this talk about aquablation. But first of all, Christopher and I would like to thank a lot the Endourological Society and all its staff to provide such high quality education and program during this tough time of COVID-19 pandemic. So this is a really tremendous effort that has honored by every of the attendees. I heard that you were more than 500 attendees today. So it's really cool to see so many people interested into robotic surgery, and especially aquablation. So we will talk about aquablation in the treatment of benign prostatic obstruction in the following hour with Christopher. So briefly, my disclosure. So I'm consultant and proctor for Boston Scientific, Richard Wolf and Procept BioRobotics.

Dr. Vincent Misrai:

So waterjet technology is not new, in fact. And if we look at the literature, waterjet energy, which is a heat-free energy, was used back in the '80s to cut the bones, in fact, and for hepatectomy. So it's not really new. What is really new is the additional value of the robotic process to do the aquablation of the prostate. And the aquablation of the prostate has been released progressively in the last years, beginning in 2014, with the first clinical case, and now, we have to notice that aquablation is a real alternative to TURP for the treatment of BPH in small to medium size glands.

Dr. Vincent Misrai:

So briefly, the AquaBeam system is composed of a conformal planning unit, so called CPU, which provide the image and planification during the treatment, a keyboard, a handpiece, you can plug handpiece. The handpiece is a single use, so it's disposable. So you plug the handpiece on the motorpack before starting the procedure. A console which will provide the waterjet, the energy. A secretion container and a foot pedal to start the procedure, the resection itself. So it's a real-time image guidance surgical procedure. And what is really new is the robotic aspect of this procedure. And in fact, it's a semi- autonomous surgical procedure. It means that we will reduce, with this procedure, some human bias. But we will develop this part after.

Dr. Vincent Misrai:

So, it's a real-time image guidance with a surgical planning. You can plan with your keyboard and with a mouse the area to treat with the waterjet. And this is a robotic-executed ablative treatment. So, robotically controlled. Here is the virtual film, virtual movie, to describe you the procedure. So you insert the TRUS ultrasound, the handpiece, and then you set the area you want the robot to treat, the waterjet to treat, and then you press the foot pedal and it will do the job automatically. Here is a short movie in real situation. So you have the prostate in your transversal view with the TRUS. So it's TRUS monitor. You have the image on the CPU, the conformal planning unit. You insert the device inside the ureter. So, you have the image here. And then you will retract... You can see on the right side of the screen, you will retract the scope at the level of the sphincter.

Dr. Vincent Misrai:

Then you have some manipulation with the keyboard and you will control the TRUS, which is fixed with a robotic arm. And you will set, in fact, the device inside the ureter and the TRUS to be colinear. You have a dedicated setting in case of median lobe, so you can treat the median lobe, and the transition zone as well. So, it's really easy to understand. In fact, after two, three, five cases, you are more confident with the technique. Then you retract the ultrasound at mid-prostate level and you will choose to extend or... You will set, in fact, the ultrasound for the waterjet to be able to treat the prostate with a depth of 24 millimeters. You cannot fit below 24 millimeters. So, you have to work to compress [crosstalk 00:09:11].

Dr. Christopher Netsch:

Dr. Misrai, I have one question. How many percent of the prostate is being ablated with this technique?

Dr. Vincent Misrai:

You can fit any kind of prostate. In fact, this robot has been released to standardize the ejaculation preservation.

Dr. Christopher Netsch:

But you have a maximum penetration depth of the water beam of 24 millimeters.

Dr. Vincent Misrai:

Of course, you can reduce the depth of the penetration.

Dr. Christopher Netsch:

But if you have a large prostate, what will you do then? How would you treat them?

Dr. Vincent Misrai:

It's a very good question. So, maybe I should pause the video. So, if you have a larger prostate, you can do additional passes, okay? Usually you do one pass with the waterjet from the level of the bladder neck to the apex. So, you will do one pass. But you can do additional passes, a second or third passes. For very large prostate, in fact, you can overcome this problem of the depth penetration, you can overcome this small issue with compressing the prostate between the handpiece, which was inserted into the ureter, and the TRUS. So, you will compress, a little bit, the prostate and you can measure the length of the prostate compressed between the disposable and the TRUS to adapt the depth of your ablation. So the main issue... But we will discuss about that further. The main issue is for long prostate because the length of the resection is standardized. So, you cannot extend the length. So, you have to set the system to be able to treat the remnant apex, for example. So we are not limited by the size of the prostate, but the longer the prostate.

Dr. Christopher Netsch:

And what will you do if you have a large middle lobe? Will you also do an AquaBeam procedure in a very large middle lobe?

Dr. Vincent Misrai:

In fact, if the patient would like a preservation of ejaculation, which means... It's easy to enucleate or vaporize the median lobe. So, my opinion is that median lobe prostate are not good candidates for aquablation. And it's easy to remove the median lobe only with enucleation or vaporization. But in fact, for small median lobe, if you extend the ablation from the lateral lobe, you can easily do aquablation. It's not a problem.

Dr. Christopher Netsch:

So, can you give us a hint, what is the perfect indication for an AquaBeam treatment? What is the perfect candidate, the perfect patient for this treatment?

Dr. Vincent Misrai:

Preferred candidate, first, from a general perspective, which mean health status, is a patient without oral anticoagulants or antiplatelet agents. We will discuss that further again. But antiplatelet agents and oral anticoagulation are providing a high risk of bleeding, increased risk of bleeding. And the coagulation with the aquablation is not perfect. We have some tips and tricks to improve the coagulation, of course, but these kind of patients are not good candidates. From a conformal anatomy of the prostate, you can treat any kind of prostate but the ideal patient is a patient with a prostate ranging from 50 to 100 grams.

Dr. Christopher Netsch:

Would you treat a 30 gram prostate with the AquaBeam procedure or will you do a TURP or [crosstalk 00:14:05]?

Dr. Vincent Misrai:

We noticed in our study in France published, as you mention, in European Urology, that for small glands you cannot visualize as good as for larger glands, the anatomy, so it's more difficult to set the ablative procedure because of the visualization. So you cannot see as good as you would like to a small prostate with the TRUS. It's more difficult.

Dr. Christopher Netsch:

So the perfect candidate, 50 grams to 70 grams, in your opinion?

Dr. Vincent Misrai:

50 grams to 90, 100 grams, yeah.

Dr. Christopher Netsch:

The perfect candidate, okay.

Dr. Vincent Misrai:

Without any oral anticoagulants.

Dr. Christopher Netsch:

Okay. So one question here from the audience was about the temperature of the water. I think it's 25 degrees, it's the room temperature of the water.

Dr. Vincent Misrai:

Room temperature. So it's a heat-free energy. So, after the ablation, we have to remove the clots, of course, because during the ablation, you will have some bleeding and some clots inside the bladder. So, you need to remove, with a syringe, all the clots. Like that. We will see that further but we need, as well, to remove the fluffy tissue because aquablation will provide, inside the prostatic fossa, some fluffy tissue that we need to remove before inserting the bladder catheter, to make sure that the bladder catheter will not be obstructed in the recovery room by this fluffy tissue. While removing this fluffy tissue, you can see some arterial bleedings. And in addition, you can coagulate with monopolar loop, for instance, the arterial bleedings. It's better for low cost. One month post-op, you have this prostatic cavity.

Dr. Vincent Misrai:

We talk about method of hemostasis because I used to say that aquablation procedure is a 22nd century procedure because of the robotic additional stature with 19th century hemostasis methods. It's the Achilles of the technique maybe. But anyway, I think it definitely will be improved over the following years or months. So, method of hemostasis changed over the studies released in the literature. For example, in the WATER studies, it was the first study handling the technique. It was [inaudible 00:17:40], in fact. The surgeon used electrocautery to do hemostasis and put a balloon into the fossa to make a balloon tamponade. In the WATER II study involving a larger prostate, two-fold more larger prostate, in fact, than in the WATER study, initial study. In this study, a catheter with a CTD, which is a catheter tensioning device. So this device was used to adapt the tension of the bladder catheter to put the balloon just at the level of the bladder neck to do the hemostasis.

Dr. Vincent Misrai:

Bladder hyperdistension was described by a Montreal team with Kevin Zorn, but is not performed now anymore. Some of us used a double balloon catheter. So it's a small device with double balloon, one balloon into the prostatic fossa and another balloon just above, at the level of the bladder neck, to make the compression and to provide the hemostasis. And nowadays, we use focal bladder neck cautery while removing all these fluffy tissue. Now, we need to talk a little bit more of evidence-based medicine and the evidence provided by the different study released in the literature. So the first study was released few years ago, three years ago, in fact, was the WATER study. It was a double-blind, prospective RCT comparing aquablation and TURP. And this study was planned to release the outcomes at six months to one year, then three years and the study will end at five years.

Dr. Vincent Misrai:

So we have the result. I will present to you the result at three years. And the results give us, with a high level of evidence, of course, that aquablation is non-inferior to TURP, again, for glands less than 80. So it's really important to notice. As you can see, the functional outcomes in this study, IPSS score and IPSS question eight, which is the quality of life. So there is no difference between aquablation and TURP, in terms of IPSS, even at three years, as well with the quality of life, no statistical difference. As well with the uroflow, so the Qmax was more or less the same, so no statistical difference. Maybe a trend for therapy to provide a less Qmax. And the PVR was exactly the same, again, at three years, so no statistical difference. That's why, in conclusion, aquablation was reported as a non-inferior technique to TURP.

Dr. Vincent Misrai:

Now, considering the PSA reduction, we have some doubts initially regarding the amount of tissue removed by the aquablation. We should expect a small PSA drop. But it's not the fact, we have exactly the same PSA drop than TURP, even at three years with a low average yearly retreatment rate of 1.4% per year. So it's very small. But again, we need to... You're aware that this is a medium term, so a short medium term. We don't have any long-term data as this technique is really new. Now, on this slide, it was the baseline characteristics between patient enrolled into the WATER study, so the first study, with a mean prostate volume of 54 grams, compared with the WATER II study, which was not a randomized control study, it was an observational prospective study for larger glands. So you can see the prostate sizes are twice bigger than in WATER study. And if the patients had more or less the same profile, except for the prostate size, the procedure outcome were slightly different, in fact. First, regarding the intraoperative time. The intraoperative time was longer for large prostate.

Dr. Christopher Netsch:

Sorry, can I give a comment in this study?

Dr. Vincent Misrai:

Yeah.

Dr. Christopher Netsch:

So, first of all, in WATER II, they did no electrocautery. So, maybe this is one reason for the longer catheter stay during the study and for the higher hemoglobin drop in the WATER II study.

Dr. Vincent Misrai:

Maybe, yes. But the size of the prostate could be, as well, a surrogate marker of the bleeding risk. The bigger is the prostate, maybe the higher the patient is at risk to bleeding. We don't know. But I think it's related to the number of passes as well. But again, the evidence is low, to be honest. But one has to notice that the hospitalization length of stay was similar between the two studies regardless of the prostate size. So it's very interesting to notice that. BPH symptoms improvement between these two studies were exactly the same. So you can see, at two years, there is no significant difference in the two studies regarding the IPSS as well for the quality of life. And we have exactly the same results with the Qmax, with no significant difference between the two studies, and the PVR as well.

Dr. Christopher Netsch:

Can I give a final comment on these WATER studies? I think it's important for auditor. So, these are very perfect studies with perfect results, maybe a little bit too perfect, because every AquaBeam procedure was done with a proctor in the OR room. So this is not real life. So maybe this might be a reason for these exceptional good results in the study. And I think this must be said if we go to the studies and to the results because they were very perfect. And the PSA drop also was very low in the TURP arm than in comparison to the AquaBeam arm. So you have to know this in mind if you look to the data of this study. And it's like in every randomized study, very good selection of patients makes very good results. But this is not what you see in the daily practice. You have the old patients with the anticoagulants and they might bleed.

Dr. Vincent Misrai:

All these procedures were done by endourological experts in the field. And one has to notice and to emphasize that, in fact, aquablation is not relying on the surgeon expertise. I will develop that in few minutes. But regardless of your expertise, you can provide the patient the same results as an expert. So, the learning curve is [crosstalk 00:27:02].

Dr. Christopher Netsch:

Sorry. The AquaBeam procedure, do we have a learning curve?

Dr. Vincent Misrai:

The learning curve of the AquaBeam procedure has been described, but the data are scarce. The fact is that, in the learning phase of the procedure, you just have to be aware of how to put the arms, how to insert the handpiece, how to do the planification. So it is not relying on your dexterity, on your surgical skills, in fact.

Dr. Christopher Netsch:

So it doesn't make any difference if you do 120 gram prostate with the AquaBeam procedure compared to a 30 gram procedure, there is no learning curve?

Dr. Vincent Misrai:

I think it's like any kind of surgery on that point. When you start a procedure, you don't put your first patient with a prostate of 200 grams, we have to be honest. Maybe there is a small learning curve and you have to select your patient, at the beginning of your experience, to avoid some bleeding complication. Because we saw that, while the prostate size is increasing, the risk of bleeding may increase as well. So, for prostate range from 40 to 80 or 90, honestly, you just have to learn how to set the system. So, this is not depending on your skills.

Dr. Christopher Netsch:

Will learning curve receive OR time or whatever?

Dr. Vincent Misrai:

This is a big issue. Because when you assess the learning curve, you can put everything in the bucket. You can put the OR time, you can-

Dr. Christopher Netsch:

No, just say, for you, it's the OR time. You've never faced any fatal complications like mass transfusion, rectal perforations or so?

Dr. Vincent Misrai:

No. Because the system will bring you so much information to prevent this kind of complication. The learning curve, in fact, is how to manipulate the system. So you have to know how to manipulate the system and you have to be aware of the trouble shootings. For example, if the system is either shut down or the system is not answering as you expected, normally, it's a tight start. So it's very progressive. But it's only technological problem, in fact. So my opinion is that the learning curve is short, but again, it's expert level. So, very low level of evidence. Level five, no level one, we need to work on that to assess the learning curve more accurately. But one of the advantages... There are some advantages, of course, is the short resection time. It's very important to notice that regardless of the size of the prostate, the resection time is remaining more or less stable compared to other ablative technique such as-

Dr. Christopher Netsch:

Sorry to intervene you. The aquablation time is short, but not the time you need to set up the prostate for the resection. So you just need 15 minutes to get the prostate perfectly.

Dr. Vincent Misrai:

In this study we published in World Journal of Urology, we consider the time-

Dr. Christopher Netsch:

Sorry. Is it fair to do this? Because if you do a laser enucleation, you have a PSA drop of 80% and that means you're very radical. And you compare this to procedure time which is shorter and you just resect 60%. So there must be a difference. You know what I mean?

Dr. Vincent Misrai:

I understand what you mean. But in this study, we didn't cheat. In fact, we assume that the aquablation time started from the TRUS insertion to bladder catheter insertion. So, it's the time of the procedure, in fact. So we compare that with PVP, with HoLEP, with green laser enucleation, with TURP, and we found that the intraoperative time, regardless of the prostate size, was stable for aquablation. And it was not the-

Dr. Christopher Netsch:

You have to say that you resect less tissue. You're not as radical as the laser enucleation procedures, aren't you?

Dr. Vincent Misrai:

Yeah, exactly. But it would be interesting to assess the Qmax and the long-term follow-up.

Dr. Christopher Netsch:

I think so, up to five years or seven years, you will see the difference.

Dr. Vincent Misrai:

I know you want to challenge me.

Dr. Christopher Netsch:

I don't want to challenge anything, it's just to say that there must be a difference if you take out 60% or 90% of the prostate tissue.

Dr. Vincent Misrai:

But maybe it won't make any difference, we don't know, with aquablation. Honestly, we don't know. So we need to assess a patient with a longer term follow-up. So another advantage of enucleation is that you can preserve, with a good standardization, ejaculation. So it's an ejaculation sparing technique. To be honest, the system was released to do that, to standardize the ejaculation preservation. And some team published their tips and tricks to improve ejaculation height preservation. And they reported that if you cut less than five millimeters below the verumontanum, you will improve the ejaculation sparing height in these kind of patient when you do that.

Dr. Vincent Misrai:

Another advantage which is, for me, one of the main and the pillar advantages of this robotic surgery is we presume that the learning curve is really short. But again, it is not depending on the surgeon expertise. So this is a semi-automatic robotic procedure. So regardless of your shape... Maybe some of us are going in the OR sometimes in the morning, so you are tired because your kids were crying all the night, I don't know. Anyway, so maybe you are not in good shape. And it's like a Tesla, you plan your address and then the Tesla will drive you safely home after a long journey, and the machine will take care of you and will see all the danger all over the car while the car will drive you home.

Dr. Vincent Misrai:

So, it's exactly the same, the surgical paradigm has changed and the success is more, depending on the instrument, and on the surgeon ability to extend or reduce the resection area. But the system will take care of the patient and will reduce maybe all the human bias. If you forget to do something, for example, to pure the system, the system will be, "Oh, are you sure you want to go ahead?" "No. Okay, I forgot that I need to pure", et cetera. So the system is evolving, no doubt. There will be more and more preventing stuff to make the potential safer and safer. Now, we have to talk about the disadvantages. So again, we don't have any long-term follow-up, which is crucial to assess a new technique, of course. Again, we are unable to safely stop antithrombotic agents. This technique is not good for patient under oral anticoagulants because when you will restart the anticoagulants, you will expose the patient to a risk of bleeding more than we've observed, for instance.

Dr. Vincent Misrai:

And the bleeding complications and the risk of transfusion is not really significant, but it has been reported up to 4% of patient transfused, in the literature. But again, this literature are concerning papers released between 2014 and 2018. So, this is what we should call historical studies. So the historical risk of bleeding was assessed to be at 4%. So, when we look at brand new data, we can see that the risk of transfusion is decreasing. Why? It's really understandable. Why? Because we improved the technique of hemostasis and we standardized the process to remove the fluffy tissue. It's very important to remove all this fluffy tissue after the operation. It takes around four minutes to remove this fluffy tissue. And then you are allowed to coagulate some small arterial bleeders. There is no need to coagulate venous bleeding, it will be managed by the catheter. But if you see an arterial bleeding, you can coagulate with a monopolar loop, whatever. It takes only few minutes.

Dr. Christopher Netsch:

One question, sorry. Do you use electrocautery in every patient?

Dr. Vincent Misrai:

No.

Dr. Christopher Netsch:

Have you had it on your OR table?

Dr. Vincent Misrai:

I have at my disposition, the monopolar TURP loop. There is absolutely no additional cost, in fact, because it's a reusable loop. And I don't use the bipolar because of the additional cost, of course. And most of the aquablation guys are using the monopolar loop to do this coagulation but it is absolutely not systematic. If you don't see any arterial bleeding after removing the fluffy tissue, there is no need to coagulate. And among that, there is no need to resect. So we need to think about the TRUS. You just have to resist. Sometimes you want to do a small additional resection but it's absolutely forbidden to do that because we have the TRUS inside, okay? So it's very dangerous to resect while the TRUS is inside because it could lead to rectal perforation. So it's not a good idea. So just focus coagulation with the monopolar loop and it will dramatically decrease the risk of transfusion, as we can see.

Dr. Vincent Misrai:

So, fluffy tissue removal and coagulation, if needed. And to conclude, I think, standardization is the key in surgery. We have many description of many surgical technique but it's a fact, when you read, when you see a procedure, there is a huge gap between reading or seeing a surgical procedure and doing the procedure. And standardization, I think, is always to reduce human bias. Because in any kind of work, you have some human bias. You can do some errors and the system, that is robotic system, is able to prevent errors with the technology. Thank you.

Dr. Christopher Netsch:

Thank you very much, Dr. Misrai. So I also use the AquaBeam systems but I try to stay critical for the use of it. Therefore, I have some other questions for you. So what are the strict contraindications for performing the AquaBeam treatment, in your opinion?

Dr. Vincent Misrai:

Contraindications, frail patients. For example, patient with a poor medical status, with medications including oral anticoagulants.

Dr. Christopher Netsch:

So what will you do in these patients?

Dr. Vincent Misrai:

Sorry.

Dr. Christopher Netsch:

What will you do in these patients?

Dr. Vincent Misrai:

I will do maybe a partial ablative treatment with the lasers because we don't-

Dr. Christopher Netsch:

Okay. So what I try to point out is, this is an interesting technique but you have to need other techniques also for the BPH treatment. So it's not that you have the AquaBeam and you can stay away from TURP, laser enucleation, laser vaporization or whatever. So this is important to know for the audience.

Dr. Vincent Misrai:

It is as well important to know, for the audience, that the goal is really the standardization, to provide the patient the same results regardless of level of expertise. And this philosophy... Maybe the system is not perfect so far, today, but I think the team will continue to improve the system. For example, to improve the coagulation, to reduce more and more the human bias. But really, I'm more interested into the standardization than into ejaculation preservation. Ejaculation preservation, we need to think about that and to propose that to the patient we will take care of. But what is interesting for the future, maybe not now, is the standardization.

Dr. Christopher Netsch:

Okay, thank you. I just have another question from the audience. It's about the histopathological examination. Is it possible to do this with AquaBeam? Do we have some histology?

Dr. Vincent Misrai:

There will be shortly released in the literature paper in the World Journal of Urology, a paper describing TURP chips and histopathological specimen after aquablation. And in fact, it's not really relevant to send these fluffy tissue to the pathologist because the information is really poor. And there is no need, in fact, to send to the pathologist the fluffy... So you need to make sure that if you have any doubt with high PSA level, to make an expertise to take out the risk of prostate cancer. But it's not really relevant to send the fluffy tissue, no.

Dr. Christopher Netsch:

So I had just one last question. One question, one short answer. In 10 years, what will we have, aquablation, Rezum, UroLift, prostatic artery embolization? What will be the winner? What's your opinion? Short answer.

Dr. Vincent Misrai:

Honestly, regardless of my conflict of interest, I should say, a device which could be able to do the surgery with limited human expertise, in fact, and so far today, the only technology which could be able to do that is the aquablation.

Dr. Christopher Netsch:

Okay, that's what I would say. I think this will be the only or the best technology. I think we will see the AquaBeam technology also in 10 years. Okay.

Dr. Amy Krambeck:

Well, this was a wonderful and informative presentation. I know the questions have been answered as we went along, that were posed from the audience, but there's a few I'd like to just reask. And one of them was, has any cost effectiveness studies been performed comparing the aquablation procedure to TURP, greenlight laser, Rezum, any information on that?

Dr. Vincent Misrai:

Honestly, so far, there is no information or no study about the cost effectiveness, but I don't like cost effectiveness word. Why? Because it depends on the country you are working in, of course. I prefer, in fact, the carbon footprint of the surgical procedure. Because the carbon footprint of your surgical procedure, we will talk about that in the following years. It's mandatory because of the global warming. And carbon footprint is universal, from a country to another. So, I don't like to say, cost effectiveness. Beside that, yes, it has a cost, of course. It has a cost and to date, the price of the handpiece, the single-use handpiece is €1500. So, it has a cost. But some patients... The national system in France is not able to cover the cost, but we are working on that to develop and to spread the technique with less cost, let's say.

Dr. Amy Krambeck:

Wonderful. This next question can go to either Dr. Netsch or Dr. Misrai. Is there any cases of treatment of prostate cancer after aquablation? So if you do an aquablation, patient develops prostate cancer, can you still go forward with radical prostatectomy, should you do radiation, is there any data on that?

Dr. Christopher Netsch:

So, in my opinion, there is no data on that, though I think you can do a radical prostatectomy. Why? Because we have one case of AquaBeam treatment and we did easily redo laser enucleation and this was no problem because you have the layers like in a genuine prostate. So I think, in the cases of prostate cancer, you might also do the radical prostatectomy. There's no problem.

Dr. Vincent Misrai:

Remember it's a heat-free source of energy. So I completely agree with that. There is nothing in the literature about radical prostatectomy after aquablation because of the follow-up, we don't have a large follow-up on aquablation. But maybe we will see some cases in the following years. So it's a heat-free procedure, so I guess that the inflammation is less important than with the laser or with PVP. Some papers have been released in the literature regarding radical prostatectomy after PVP, and it's very difficult because of the inflammation even months and years after the BPO surgery.

Dr. Amy Krambeck:

Perfect. And then another question that came through was retrograde ejaculation. I do enucleation, so I tell all of my patients, "You will develop retrograde ejaculation." When you are counseling a patient that is going to undergo aquablation, what do you tell them the risk of retrograde ejaculation is?

Dr. Vincent Misrai:

I select the patients first, I don't know about Christopher. I'm very aware of the patient selection. And for example, I do not offer aquablation for patient with prostate less than 40. So between 30 and 40, I don't do aquablation. I do aquablation from 40 to 90, 100, 102, et cetera. And roughly, the retrograde ejaculation rate is 20% after the procedure. So we have more than 80% of the patients with no ejaculation dysfunction.

Dr. Amy Krambeck:

Wonderful. Okay. And there's no effect on erections, correct? So erectile function is unchanged.

Dr. Vincent Misrai:

No, unchanged. No significant improvement, of course. No significant drop of IIEF-5 and the erectile function remains stable from pre-op to post-op course.

Dr. Amy Krambeck:

Okay. So if a physician is interested in learning aquablation, do they contact the rep and the representative would bring the machine in? And how many cases should they do with the representative present before they can go on their own? I know it's really just the setup. I actually participated in WATER II, so I know it's a quick learning curve there. But really, what would you expect someone to plan for, two or three days with the rep or what would you think?

Dr. Vincent Misrai:

Yeah, two or three days. You can schedule five or six or seven patients and you will know all the basics for this technology. But I have to note that the team is very reactive. If you have a trouble, you can join with FaceTime and they we fix any kind of problem in a minute. And you can take the hand of the machine as well with internet. So it's very easy to learn, with a good patient selection.

Dr. Amy Krambeck:

Yes. I think with any technology, patient selection is paramount, right? And then finally, how long will it take for the patient to notice a change in their urination, is it immediate or is it somewhat good and then it improves over a few weeks? How does that work?

Dr. Vincent Misrai:

In fact, it's really quick. The issue is when the patient put some pressure on your shoulder and ask you to preserve 100% ejaculation. There is a time to modify the planification and you will reduce the ablation treatment. There is a risk, so you have to be confident with the initial setting. Because the machine will give you its own settings, in fact, and you can modify the settings proposed by the machine. And if you extend the preservation of the apex, there is a risk for the patient not to have a very good flow on the postoperative. But if you trust the machine, the patient is able to pee very well immediately after the bladder catheter removal.

Dr. Amy Krambeck:

This will be my final question before we sign off. What are their voiding symptoms like afterwards? I know with some laser procedures, there's dysuria, urgency, frequency, is that an experience with the aquablation system or not?

Dr. Vincent Misrai:

In fact, this is only expert level. So, very poor level of evidence. And again, this level of evidence could be influenced by the disclosures, of course. There is no perfect study that compared postoperative urinary symptoms after aquablation and laser ablation, for example. But we could imagine that the temperature of the energy source would influence the postoperative voiding symptoms. But honestly, I couldn't say that there is less urge symptoms on the postoperative course than with the lasers. It could be a nonsense regarding the poor level of evidence.

Dr. Amy Krambeck:

Okay. Well, that's an honest, fair answer. I like that. So I would like to thank the audience for joining us today. It was a wonderful presentation, very informative. I, personally, learned quite a bit and I'm sure the audience did as well. Next week on September 11th, we will be having presentation on robotic partial nephrectomy. The surgeons will be Dr. Sundaram and Dr. Porpiglia and the moderators will be Dr. Shalhav and Dr. Kaouk. And I think this will be a phenomenal presentation. I would also like to remind everyone that you can get CME credit for today. You will receive a survey from Michele Paoli. You just indicate which seminar you attended and you will get your CME certification from there.

Dr. Amy Krambeck:

And then finally, I would like to encourage everyone to join the Endourology Society if you are not already a member. It's very easy to become a member. And there's multiple benefits such as full text online for the Journal of Endourology and Videourology. So just go to the website to join. And finally, I would like to remind everyone that we are still planning the WCE in 2021 in Hamburg, Germany on September 21st through to 25th. So I'm sure we'll all be looking forward to meeting each other in person at that time. Thank you for joining today.