Aquablation: the image-planned robotic waterjet

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who gets the waterjet The bigger gland, from about thirty up to 150 grams where a resection would be long and an enucleation is the usual alternative; the man who wants ejaculation preserved, which the plan can protect by sparing the tissue around the verumontanum and the ejaculatory ducts; and the surgeon who wants the resection to be reproducible and short. The trade-offs are bleeding, which is the main complication and the reason for a night in hospital with irrigation, a general or spinal anaesthetic, and the capital cost. Histology is available from the fragments, though the tissue is disrupted.
2. Consent and the set-up The consent names bleeding first: transfusion in a few per cent, a return to theatre for clot or haemostasis, a catheter with irrigation overnight; then infection, retrograde ejaculation in a minority when the plan spares the veru, retention at the trial without catheter, the small risks of incontinence and stricture, and retreatment in a proportion. Lithotomy under general or spinal anaesthetic. The transrectal ultrasound probe is placed and fixed on its arm; the 24 French handpiece with its telescope is passed into the bladder under vision and locked to the same arm, so that the two cannot move against each other during the plan or the cut.
3. The handpiece The handpiece sits in the prostatic urethra with the verumontanum and the sphincter behind its tip and the bladder neck ahead. The endoscopic view is checked against the ultrasound: the tip position on the screen matches what the lens sees. The probe gives a sagittal view of the whole urethra and a transverse view at any level, and the surgeon works from both. The patient is not moved, the arm is not touched, and the bladder is kept at a constant fill from now on.
   where it bites: the probe and the handpiece are locked to one arm; if either moves, the plan no longer describes the anatomy.
4. The plan on the ultrasound On the sagittal image the contour of tissue to remove is drawn from the bladder neck to a point short of the verumontanum, with the veru and the sphincter beyond it inside a safe zone where the jet is turned down or off. The distal limit is drawn from the veru on the image, not estimated. On transverse slices at several levels the depth is set to the surgical capsule, so that the jet stops at the same plane the loop would; laterally the contour follows the lobes. At the neck the contour is drawn to spare the trigone and the ureteric orifices, which sit behind a large median lobe.
   where it bites: the plan is checked against the endoscopic view before the pedal: the safe zone at the veru and the orifices out of the neck contour.
5. The jet With the plan confirmed the foot goes on the pedal. A high-velocity jet of saline emerges from the handpiece at right angles and sweeps side to side through its arc while the handpiece retracts along the plan under the robot's control, cutting the adenoma without heat and sparing the capsule and the vessels of the neck to a degree, because the jet cuts soft tissue before firm. The surgeon watches the endoscopic view and the ultrasound together; the field fills with fragments and blood and the ultrasound shows the cavity forming to the contour. A hand near the pedal stops the jet at once if the field is lost or anything moves. Four to six minutes for most glands; the plan can be run twice for a very large one.
6. Haemostasis The jet stops nothing, and a raw bed the size of the gland is now bleeding. The handpiece comes out and a resectoscope goes in. The cavity is inspected sector by sector with the irrigation slowed, and focal cautery is applied with the button at the bladder neck at five and seven o'clock where the arteries enter, on the points, not painted across the bed; the orifices are kept in view. The rest of the bed is left for the catheter: coagulating the whole cavity undoes the advantage of a cut made without heat. Some units use the button routinely at the neck; others rely on traction alone. Both orifices are seen again with their jets.
   where it bites: the neck arteries at five and seven o'clock sit a centimetre from the orifices; the button goes on the point.
7. The catheter and the note A 22 French three-way catheter goes in, the balloon is filled large and pulled down onto the bladder neck for traction, and the catheter is taped to the thigh. Continuous irrigation runs overnight until the effluent is rosé and the traction is released in the morning. The haemoglobin is checked the next day. The note records the plan volume and the resection time, the cautery used and where, the orifices and the veru seen intact, the catheter, the traction and the irrigation plan, and the fragments sent for histology.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance