2 The condition, current treatments and procedure
2.1 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.
2.2 Mild symptoms are usually managed conservatively. Drugs may also be used, such as alpha blockers and 5‑alpha-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.
2.3 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 3‑way 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.
2.4 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.