Advice

The technology

The technology

Aquablation robotic therapy (Procept BioRobotics) is a technology used for the removal of obstructions for people with lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). The system consists of a robotic handpiece, console and conformal planning unit. Resection and removal of prostate tissue is done using a water jet from the robotic handpiece placed within the urethra. This method is known as transurethral water jet ablation. Transrectal ultrasound is used before the procedure to map out the region of the prostate to be resected and allow real-time imaging of tissue resection during the procedure. Positioning is confirmed using visual markers on a computer screen and the surgeon can plan the depth and angle of resection using the system software. Once the surgical mapping is complete, a high-speed jet of saline is delivered to the prostate at various flow rates based on the depth of penetration needed. The ablated tissue is aspirated through ports in the handpiece and can be used for histological analysis. After resection is completed, haemostasis is done around the bladder neck using focal thermal energy from a standard resectoscope. The procedure is usually done with the patient under general or spinal anaesthesia.

Innovations

Resection of prostate tissue using transurethral water jet ablation does not use heat, unlike other resection techniques, which reduces the risk of complications from thermal injury. Other advantages of the technology are that it can be used on prostates of any size and shape and has the potential to preserve sexual function.

Current care pathway

Mild LUTS caused by BPH is usually managed conservatively. Drugs such as alpha blockers and 5-alpha-reductase inhibitors may also be used. If these treatments have not worked, there are a range of surgical options that may be considered. These include transurethral resection of the prostate, transurethral vaporisation, holmium laser enucleation, transurethral incision of the prostate, insertion of prostatic urethral implants and prostatectomy.

The following publications have been identified as relevant to this care pathway:

Population, setting and intended user

Aquablation therapy is intended to be used to treat people with LUTS caused by BPH. The technology will be used by a urologist in secondary care when drug treatments and conservative management options have failed. The manufacturer provides a training program for Aquablation therapy at no additional cost, which is to be completed before using the system. Follow-up training via online modules and surgical observation is also available. The company states that surgeons need approximately 10 to 12 cases to develop sufficient familiarity with the system.

Costs

Technology costs

The company estimates the cost per patient to deliver Aquablation therapy is £2,872.42. This is a volume-based price and includes the capital costs, with no separate robotic unit to purchase. This includes a per patient consumable cost of £1,925 (excluding VAT).

Costs of standard care

The cost of standard care is variable depending on the technology used. The costs per patient of some comparator technologies have been taken from supporting documentation in NICE's medical technologies guidance on GreenLight XPS for treating benign prostatic hyperplasia:

  • Monopolar transurethral resection of the prostate £3,091.97

  • Holmium laser enucleation of the prostate £3,056.66

  • Greenlight £2,782.14.

The company claims that the technology is likely to be cost saving compared with standard care because of the following factors: reduced theatre time, reduced length of hospital stay, ability to provide the procedure as day case, reduced retreatment rates and reduced adverse events. But there is limited evidence to support these claims.

Resource consequences

Aquablation therapy is currently being done in 5 NHS centres. The company has estimated that approximately 28,000 people would be eligible for treatment with the technology each year.

Aside from purchasing the system and training staff, no changes in facilities or infrastructure are associated with adopting the technology.