Robotic Waterjet Resection for Men With Prostate Cancer Suffering From Lower Urinary Tract Symptoms
- urologyxy
- Feb 15, 2025
- 3 min read
Objective
To evaluate the impact of Aquablation on circulating tumor cells (CTCs) in men with localized prostate cancer.
Methods
This prospective study included subjects with biopsy-positive mpMRI visible lesions (PIRADS ≥3) who underwent Aquablation. Ten mL blood samples were collected before, during and after the procedure to measure CTC counts using an immunofluorescence assay.
Results
The mean age of participants was 63.4 years, with a baseline PSA of 8.9 ng/mL and a prostate volume of 60.3 mL. All subjects experienced reduced IPSS scores and stable or improved SHIM and MSHQ-EjD scores. Detectable CTCs were found in 80% of subjects before Aquablation, 100% immediately after Aquablation, 20% on post-op day 2, and 60% on post-op day 7. The mean number of CTCs per patient 10 mL blood draw was 1.2 preoperatively, 3.2 immediately post-op, 0.2 on day 2, and 1.0 on day 7. Prostate volumes decreased significantly at 3 and 6 months, with corresponding reductions in PSA levels. There were no adverse events reported. Specifically, no instances of incontinence, erectile dysfunction, ejaculatory dysfunction, or rectal toxicity were observed. At 6-month follow-up, all baseline mpMRI lesions were no longer visible on mpMRI and follow-up biopsies showed no grade group progression.
Conclusion
In an active surveillance population, Aquablation resulted in improved urinary function, stable or improved sexual function, and a transient spike in CTCs lasting <2 days that did not result in any oncologic concern. Aquablation may be considered a safe option for men with localized prostate cancer who require treatment for LUTS due to BPH.
Aquablation, a minimally invasive resective technology has the potential to be a cancer therapy. It is an established treatment for lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia that physically removes tissue as opposed to ablating in situ. A theoretical concern is circulating tumor cell (CTC) spill. Assays CTCs measure the cells that are shed from tumors into the bloodstream. CTCs are not a surrogate for metastasis and they have been found in up to 40% of men with treatment naïve localized prostate cancer.1-3 This is in large part due to the physical forces and immune response encountered by a CTC when it enters the bloodstream which results in the CTC half-life of less than 30 minutes.3-6 Any physical manipulation of the prostate, be it digital rectal exam, biopsy, surgery, TURP, or enucleation, has the theoretical potential to cause tumor cells to shed for a transient period of time. The magnitude of actual CTC release is minute and inconsequential in comparison to the integral release of naïve localized prostate cancer and there is a substantial body of evidence supporting the lack of metastatic risk posed by physical diagnostic or treatment manipulation of the prostate as reviewed below.
A recent meta-analysis investigated association between CTCs and biochemical recurrence following radical prostatectomy and radiotherapy.7 This analysis differentiated between primary circulating tumor cells (PCTCs) and secondary circulating tumor cells (SCTCs). PCTCs are early-stage circulating tumor cells that have not yet formed secondary tumors, while SCTCs are more advanced and have already formed secondary tumors in other parts of the body. It is PCTCs which are relevant and the meta-analysis which included 12 studies with 1917 participants and found no significant association between pre-treatment PCTCs and biochemical recurrence following definitive local therapy.
Aquablation is a safe and effective minimally invasive surgical technique included in many urologic guidelines as an appropriate option for the management of LUTS due to BPH.8-10 A physiological study (The PRCT study) was conducted assessing whether Aquablation could lead to metastatic seeding due to intravasation of cancer cells into the bloodstream by release of CTCs.
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