Risultati perioperatori e funzionali dopo Aquablation e prostatectomia semplice robotica assistita per il trattamento dell'iperplasia prostatica benigna: uno studio comparativo in un centro di assistenza terziaria.

Background: Modern literature increasingly focuses on minimally invasive techniques for treating lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), aiming to preserve sexual function, including anterograde ejaculation. Although several ejaculation-sparing options exist for medium to small volume prostates, only two techniques have emerged for medium to large prostates: Aquablation and robotic-assisted simple prostatectomy (RASP). Objective: The main objective was to evaluate the safety profiles of Aquablation and RASP procedures, focusing on complications, blood loss, hospitalization duration, and continence rates. Secondary aim included examining and comparing functional micturition and sexual outcomes of those two innovative techniques. Methods: We conducted a retrospective analysis using data from our prospectively maintained database of patients who underwent either Aquablation or RASP between 2017 and 2022 in our third level center for surgical treatment of BPH (San Luigi Gonzaga University Hospital). Aquablation procedures were conducted by two experienced surgeons (D.A and S. D. L) using AquaBeam (Procept) system, while RASP was performed by a highly experienced robotic surgeon (F.P.) using a da Vinci X or Xi Surgical System. A total of 109 Aquablation and 116 RASP cases who met the inclusion criteria were enrolled. Postoperative outcomes were evaluated at 1, 3, 6 and 12 months. Results: Aquablation cohort exhibit a shorter median operative time (62 ± 14.6 min vs 109 ± 24min, p<0.001), along with shorter durations of hospitalization (median 4 vs 5 days) and catheterization (median 3 vs 4 days) (p < 0.05). The rate of early complications was slightly lower in Aquablation group, however, RASP also maintained minimal rates of major postoperative complications with comparable results. The second significant finding indicates that postoperative micturition outcomes are excellent in both groups, with no significant difference between the two techniques at each timepoint. Multivariable analysis (MVA) indicated that of the included variables only preservation of veru-montanum and prostatic urethra are associated with the preservation of antegrade ejaculation for both procedures. The final key finding pertains to sexual outcomes, with the Aquablation group showing a significantly higher rate of ejaculatory function preservation (86% vs. 75%; p=0.015). Nevertheless, the scores obtained from the pre- and post-procedure MSHQ-EjD and SHIM questionnaires showed no differences between the two techniques (p=0.42 and p=0.55, respectively). Limits: Study limitations include its retrospective design despite prospective data collection, a relatively small sample size compared to similar studies, a short follow-up period limiting conclusions about long-term outcomes, potential bias as the surgeons are highly experienced, and the inability to assess the volume of prostatic adenoma removed. Conclusion: Both Aquablation and RASP prove to be safe and efficient interventions for managing LUTS arising from BPH. Aquablation exhibits a lower risk during the perioperative period and demonstrates greater efficacy in minimizing postoperative ejaculatory dysfunction. To establish conclusive findings, additional studies with sufficient sample sizes and extended follow-up durations are necessary.