LAUSR

available at http://pubmed.ncbi.nlm.nih.gov/30734990 Editorial Comment: As more technologies for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia are investigated, receive regulatory approval and are brought to market, we are left wondering where they all fit in our urological practice. Some of these decisions are data driven, and others are driven by financial concerns, including net reimbursement and cost of goods. Moreover, patients in their quest for knowledge search the Internet for the ultimate expert, Dr. Google, which can drive discussion for therapy as well. It seems that the current state of affairs suggests that developing familiarity with at least 1 minimally invasive therapeutic device, either in office or in an outpatient facility, and comfort with a surgical approach in the operating suite are reasonable therapeutic aims for our patients. The question then becomes which one or ones? Most of us tend to become comfortable with our surgical procedures using a single method such as bipolar electrovaporization and/or laser approaches achieving vaporization, resection or enucleation. Urologists develop a comfort zone with surgical procedures based on prostate size. When it is too “large,” they will opt for simple open or robotic prostatectomy. The data herein suggest that for prostates 80 to 150 gm aquablation is a good option, improving symptoms and, unlike enucleation techniques, preserving ejaculation. My own experience has evolved as well. Having been an investigator for the WATER II trial and treated patients subsequently out of protocol, we have found this technique to be quite effective for large prostates. This approach has evolved to either an outpatient or 23-hour stay with the catheter removed the day after the procedure. Even in prostates as large as 250 gm our protocol remains the same. Finally, the issue of bleeding is much improved by coagulation of the bladder neck with a loop electrode. While it’s still early, it is entirely plausible that the days of simple prostatectomy are dwindling and, certainly for prostates too large for a transurethral approach, aquablation will be the preferred method. Time will tell. Steven A. Kaplan, MD Suggested Reading Gilling P, Barber N, Bidair M et al: WATER: a double-blind, randomized, controlled trial of aquablation vs transurethral resection of the prostate in benign prostatic hyperplasia. J Urol 2018; 199: 1252. 0022-5347/20/2044-0853/0 THE JOURNAL OF UROLOGY 2020 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. https://doi.org/10.1097/JU.0000000000001205 Vol. 204, 853-885, October 2020 Printed in U.S.A. www.auajournals.org/jurology j 853 Copyright © 2020 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.