Northwestern MedicineCase Report: A Prostatectomy after Aquablation Therapy

Prostate Cancer Diagnosis Post-Aquablation Therapy: Implications for Surgical Management and PSA Monitoring

In a detailed examination of prostate cancer management post-aquablation, Edward M. Schaeffer, MD, PhD, provides insights into the challenges and procedural nuances faced during robotic prostatectomy after aquablation therapy. The case study of a 74-year-old male, previously treated with aquablation for an enlarged prostate, underscores the complexity of subsequent cancer treatment due to residual prostate tissue and PSA levels that remained elevated, offering critical learnings for clinicians in similar situations.

Key Points:

• A 74-year-old man with progressive lower urinary tract symptoms and a prostate size of 140 grams had a PSA level of 9.4 at initial evaluation.
• Post-aquablation, the patient’s prostate reduced slightly to 120 grams, and PSA was 9.3, indicating minimal impact from the aquablation procedure.
• Persistent elevated PSA levels post-aquablation (9.35) are concerning as they suggest incomplete removal of PSA-producing tissue and potential presence of aggressive prostate cancer.
• Northwestern Medicine does not typically perform aquablation; instead, they prefer High-Intensity Focused Ultrasound (HIFU) due to its more effective tissue removal.
• Diagnostic imaging post-aquablation revealed a substantial residual anterior prostate component, complicating the surgical approach.
• The surgical team opted for a robotic prostatectomy, carefully navigating altered anatomical structures due to previous aquablation.
• MRI analysis showed incomplete tissue ablation by aquablation, particularly in the prostate’s anterior section, which was not fully addressed by the procedure.
• During surgery, challenges included identifying and preserving the urethral orifices and effectively managing distorted dissection planes around the prostate.

“This is a worrying sign; you want to see the PSA numbers drop below one after a definitive outlet obstruction procedure. That’s a clear indication that you’ve cleaned out all of the PSA-producing tissue and you’re unlikely to harbor an aggressive, lethal cancer.”
– Dr. Edward M. Schaeffer, Chair and the Edmund Andrews Professor of Urology at Northwestern Medicine

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