For many years, surgeons tried to develop new methods and techniques to facilitate their job.
More recently, open surgery is being replaced by laparoscopic procedures whenever possible.
Moreover, current research has developed minimally invasive treatment options.
They offer patients new treatments that do not involve cutting through the skin.
In the field of benign prostatic hyperplasia, one BPH treatment is water-induced thermotherapy (WIT).
It is similar to other minimally invasive procedures that achieve thermal injury of the prostate through radiofrequency, laser, or microwaves (1).
This technique stands as an alternative to transurethral resection of the prostate (TURP).
Studies are promising, with excellent results and tolerance levels.
You may also find this technique as Hot Water Balloon Thermoablation or Fast Liquid Ablation of the prostate.
What is it about? How does this BPH treatment work?
Who will benefit from this technique, and what side effects should we know before trying it out?
We will cover these questions on this BPH treatment option in the following article.
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What is water-induced thermotherapy?
Water-induced thermotherapy of the prostate is a minimally invasive procedure to cure BPH.
It achieves a thermal lesion in the prostate gland through the application of hot water.
The rapid flow of heated water causes coagulative necrosis of the prostate, leading to ablation of the gland.
In other words, it kills target cells and clears the way from the obstructing prostate tissue.
This procedure uses a disposable catheter connected to a console that heats the water.
The technician can also control the treatment status, timing, and other parameters from the console.
The catheter also connects to a balloon near the tip.
It inflates to keep the catheter in place. This balloon is not filled with heated water and will not damage the urethra or the bladder neck.
A second balloon is located in the prostatic urethra. This is where the heated water goes (1,2).
How does it work?
The procedure starts by administering topical anesthesia to your urethra. The doctor will then insert the catheter.
Once positioned into the bladder, the catheter will be anchored by inflating the balloon.
After that, the doctor turns on the console, and the hot water starts to flow in the prostatic urethra.
The temperature of the water reaches 60ºC. The procedure only lasts 45 minutes, counting the warming up and cooling down of water.
When the balloon expands in the initial phase of the procedure, it compresses the target tissue. Such compression of the prostate reduces the blood flow to the gland temporarily.
By doing so, the heat does not dissipate, and the surface area in contact with heat increases.
Meanwhile, the bladder neck is protected by the inflated balloon, which does not have a heated source (1).
Can it treat BPH?
Studies published so far have evaluated the tolerance of the procedure and what happens in the prostate gland.
After hot water thermoablation, the prostate reaches a temperature of up to 43ºC.
Local anesthetics are usually enough, and most patients do not feel discomfort with this temperature.
All patients, even those who reported discomfort during treatment, had the same extent of necrosis.
What this treatment does is burn part of the prostate and kill cells using a high temperature.
These cells are then cleared from the prostatic urethra, and the symptoms of benign prostatic hyperplasia improve.
It does not solve prostate enlargement but reduces the effect of an enlarged prostate in the urinary tract (3).
This effect is not immediate.
The necrotic tissue will stay in place for some time. It will be slowly absorbed from the urethra.
When it does, the mechanical obstruction caused by this excess prostate tissue will clear out.
Other studies also suggest that heated water changes the disposition of adrenaline receptors in the muscle fibers.
Thus, it has a similar effect to that of tamsulosin and other alpha-blockers.
Neuromodulation (nerve tissue changes) in response to heat may also reduce irritative symptoms (4).
Followed-up patients report improvements in their lower urinary tract symptoms.
However, these improvements might be only temporary.
After two years, lower urinary tract symptoms are likely to return.
Still, almost 90% of patients are satisfied with the procedure and report no discomfort or side effects.
Their prostate volume did not go back to normal but reduced by around 3 ccs (2).
Who is a good candidate?
You may find this method interesting, but that doesn’t necessarily make you a good candidate.
Water-induced thermoablation is recommended for a particular type of patient.
The ideal candidate would meet most if not all of the following requirements (4):
- Patients with benign prostatic hyperplasia who already have urinary outflow symptoms caused by an enlarged prostate (symptomatic BPH).
- Patients should ideally be over 50 years old to consider this and not another treatment as an option.
- The prostatic length should be higher than 2 cm and lower than 6.4 cm to ensure a better outcome after WIT.
- You should only consider WIT if medical therapy fails to achieve improvements. Patients with intolerance or allergic reactions against medical treatment are also good candidates.
- The International Prostate Symptom Score should be 11 or more. This is a test to measure how severe symptoms are.
- The urologist should run a uroflowmetry to measure the urine flow. Peak urinary flow rate should be 15 mL per second or less.
This procedure has not been widely tested in patients with prostatitis, prostate cancer, and pelvic pain syndrome. These patients are not ideal candidates.
Contraindications
There is not a guideline to use WIT, but most doctors agree that it also has relative contraindications:
- Doctors do not recommend this treatment for cases of prostate cancer or suspected prostate cancer.
- Patients with a PSA of 10 ng/mL or more may not be good candidates.
- If the patient had previous rectal surgery, a prostate surgical procedure, or pelvic irradiation, they wouldn’t be an ideal candidate for WIT.
- Doctors do not recommend this treatment for patients with a bladder neck contracture or urethral stricture.
- Patients with immune deficiency or an active urinary tract infection should treat their baseline condition before going through this procedure.
- Doctors do not recommend this treatment for patients with neurogenic bladder or a very large prostate.
- If the postvoid residual urine volume is 250 mL or more, the patient may not find significant benefit from this treatment.
How to prepare for water-induced thermotherapy
Before the procedure, your doctor will run a few tests and evaluations to make sure you’re a candidate.
You will need to go through something called cystoscopy.
This diagnostic test determines the measurement of the prostatic urethra and other parameters.
Depending on this measure, your doctor will choose the appropriate balloon length (1,2).
Another critical step to prepare for WIT is administering prophylactic antibiotics.
They will be required before and after the procedure to prevent infections.
You need to follow instructions to the letter if you want to avoid complications.
Benefits
This is not the most common procedure to treat BPH, and the literature is scarce.
However, most patients have had excellent results.
Water induced thermoablation offers these benefits (1,4):
- Improvement of urinary problems or urinary symptoms, which is probably the most important. Patients feel significant reductions in discomfort levels and symptoms such as nocturia and increased urinary frequency.
- Urine flow rate changes, which increases urinary output and the strength of the urinary stream.
- A reduction of residual urine volume. In other words, urinary retention after voiding reduces, and the patient feels they’re not holding back urine anymore.
- The procedure does not require general anesthesia. Thus, you don’t have to worry about complications of anesthetic drugs.
- It is an ambulatory procedure performed in one hour or less. After that, the patient can go back to their usual activities.
Side effects
After treatment, your doctor will leave in place a catheter for a variable time.
It is usually one week, but some patients may need it for a longer time.
Keeping the catheter in place for a longer time increases the risk of side effects.
In a 2-year follow-up study, patients reported a few adverse events (2):
- In 32% of cases, patients may have a symptomatic or asymptomatic urinary tract infection.
- Patients may experience recurrent bleeding in the urine (hematuria) in 22% of cases.
- 11% of patients reported a burning or painful sensation when urinating (dysuria).
There is no risk of erectile dysfunction, and patients did not experience a reduction of sexual interest.
Thus, it is also a prostate treatment that keeps the sexual function intact.
Risks
Besides the side effects listed above, there is something else to consider before adopting this technique (1):
- Some researchers describe a turbulent period of recovery after surgery.
- The equipment can be expensive and requires an initial investment.
- Different groups have had different results using the same technique. They are sometimes contradictory.
- The outcomes can be variable and contradictory according to scientific findings.
- There is no retrieval of prostatic tissue for pathological analysis. Thus, doctors need to rule out prostate cancer before attempting the procedure.
For all of the above, water-induced thermotherapy is not a common BPH treatment.
Doctors only consider it in very specific cases, as laid out above.
There are also concerns about the long-term.
Researchers have described the possibility of causing heat injuries in the gland and the urethra.
Such injuries could lead to tissue sloughing and recurrent urinary tract infections (4).
Water-induced thermotherapy vs. other BPH treatment options
Water-induced thermotherapy stands as a promising alternative to other BPH treatment options.
For instance:
Medical treatment
This is the mainstream BPH treatment.
It usually has outstanding results in patients with mild or moderate enlargement.
We can administer medical treatment with BPH medication such as tamsulosin or finasteride.
However, some patients experience side effects of these drugs and prefer to look for other options.
When medical treatment fails, WIT can be an excellent alternative.
Transurethral resection of the prostate (TURP)
This is the most common BPH surgery in cases of moderate and severe enlargement of the prostate.
However, it has a higher rate of side effects such as incontinence, blood loss, erectile dysfunction, retrograde ejaculation, etc.
Compared with WIT, this technique is much more effective but also has more side effects.
Other minimally invasive techniques
Thermal ablation of the prostate can be achieved with laser therapy, radiofrequency, and other methods.
These techniques are more expensive and more commonly used in prostate cancer.
Prostate artery embolization
It is a procedure to reduce BPH symptoms and prostate size.
Similar to WIT, it triggers necrosis of the enlarged prostate tissue. It is also a minimally invasive procedure.
However, it consists of blocking the blood flow to certain parts of the prostate instead of applying heat.
This procedure might not be appropriate for all patients, especially if they have atherosclerosis in the prostate arteries.
Holmium laser enucleation
This is a more complex procedure that requires general anesthesia.
It is an excellent option because it allows taking a sample of the prostate.
It offers the possibility of removing a more considerable amount of tissue.
However, the rate of complications and recovery is more challenging to deal with.
Conclusion
Water-induced thermotherapy is a BPH treatment technique without invasive surgery.
Unlike surgical treatment, it doesn’t require general anesthesia, and no transurethral incision is made.
It consists of filling the prostatic urethra with a catheter filled with hot water.
The heat would cause necrosis of the tissue, which reabsorbs and causes symptom relief, reducing the volume of the enlarged prostate gland.
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