A significant international clinical trial, led by the UK, is currently underway to evaluate a novel treatment for prostate cancer known as aquablation. This high-pressure water jet technique aims to address one of the most debilitating complications of existing prostate cancer therapies: erectile dysfunction and urinary incontinence. Up to 80 percent of men who undergo a radical prostatectomy, the surgical removal of the prostate, experience erectile dysfunction, and many also suffer from incontinence. By precisely removing only cancerous tissue, aquablation seeks to preserve the sensitive nerves that control erections and ejaculation, thereby improving the quality of life for patients.

Prostate cancer is a prevalent disease, affecting approximately 60,000 men in the UK annually. Current treatment options include chemotherapy, radiotherapy, and hormone therapy, which suppress testosterone production to inhibit tumour growth. For men with localised cancer that has not spread beyond the prostate, around 5,000 undergo a radical prostatectomy each year. While highly effective at eradicating cancer, this surgery carries a substantial risk of damaging nerves and arteries vital for erectile function. Although modern nerve-sparing surgical techniques can mitigate these risks, not all surgeons are equipped to perform them.

Aquablation is not entirely new to the NHS, having been successfully used for years in the treatment of benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate. BPH typically causes symptoms such as frequent urination or difficulty passing urine due to the swollen prostate pressing on the bladder or urethra. Similar to prostate cancer treatments, surgery for BPH, which affects around 50,000 men annually, also carries a risk of impotence and urinary incontinence. To reduce these side-effects in both BPH and cancer, various therapies like laser treatments and radiofrequency ablation have been developed. However, these methods often use heat, which can inadvertently damage healthy surrounding tissue. Aquablation stands apart by using room-temperature salt water to precisely blast away diseased tissue. Trials for BPH have demonstrated its effectiveness in easing symptoms while crucially preserving erectile function in approximately 90 percent of men.

Now, aquablation is being rigorously tested for men with early-stage prostate cancer, where the disease is confined to the gland. The UK-led international trial is recruiting 280 patients, with several prominent London trusts including The Royal Marsden, Guy’s and St Thomas’ NHS Foundation Trust, and the Royal Free London NHS Foundation Trust, alongside Norwich and Norfolk University Hospitals NHS Foundation Trust, participating among at least 20 other centres globally. Approximately three-quarters of the trial participants will receive aquablation, while the remainder will undergo a traditional prostatectomy, allowing for a direct comparison of outcomes.

The aquablation procedure involves several meticulous steps. Patients in the aquablation group first undergo an ultrasound to precisely map the cancerous areas within the prostate. While under general anaesthetic, a tube fitted with a miniature camera is inserted via the urethra to provide a magnified view of the prostate. A thin probe is then advanced through the urethra, through which water is pumped under high pressure. This probe is robotically controlled and overseen by a surgeon, allowing it to be programmed to automatically adjust the water jet’s pressure based on the amount of tissue requiring removal. Rather than a continuous stream, the probe emits water in rapid, short pulses to prevent fluid overload. A pump simultaneously suctions out the fluid along with the fragmented cancerous tissue. Any bleeding from the prostate is then meticulously stopped by cauterising the blood vessels using a heat probe.

Six months following the procedure, the erectile function and urinary incontinence of both the aquablation and prostatectomy groups will be critically compared. While promising, the procedure is not entirely without its initial challenges. Some BPH patients, for instance, have reported a burning sensation during urination or blood in their urine immediately after the water jet treatment, which is attributed to temporary damage to blood vessels. Studies indicate that full recovery can take a few months.

Expert opinions on the trial are cautiously optimistic. Neil Barber, a consultant urological surgeon at Frimley Health NHS Foundation Trust, notes that previous small trials in Hong Kong and the US have shown the procedure to be safe with very few complications for prostate cancer, though data on its long-term cancer treatment efficacy is still pending. Mr. Barber also highlighted the increased technical difficulty and duration of the procedure for cancer compared to BPH. He explained that treating cancer necessitates targeting a much larger area of the prostate without harming the surrounding nerves crucial for erectile function or the bladder, making it a more technically demanding two-hour operation, compared to 50 minutes for BPH. Professor Roger Kirby, a leading prostate surgeon and former president of the Royal Society of Medicine, who himself was diagnosed with prostate cancer, welcomed the innovative trial. However, he cautioned that while aquablation would almost certainly reduce the side-effects associated with prostatectomy, this might come at the potential expense of an increased risk of local or distant cancer recurrence, especially since the prostatic capsule – a thin layer surrounding the gland where many cancer cells originate – is left intact.