aquablation and retro ejaculation

Hi gentlemen,

I can comment on a few of the posts.

RE (retrograde ejaculation) or Anejaculation (no fluid at all - so men don't see the ejaculate in their urine when they void after orgasm) is sometimes an unavoidable consequence of even the most apical tissue sparing BPH approaches. The trap door that keeps the fluid from going back into the bladder is thought to be at the part of the prostate closest to the sphincter or "check valve" which attaches to the urethra. The opposite end of the prostate that connects to the bladder is thought to not be very vulnerable for either problems with ejaculation or erections.

Treatments that try to spare ejaculation essentially minimize operating on the area where the trap doors exist. Aquablation uses transrectal ultrasound in real time to 1. spare the tissue near the verumontanum (also referred to apical tissue) to leave the important tissue behind and 2. optimize depth of resection down to but ideally not through the prostate capsule. So how is it then that men could possibly lose ejaculation after aquablation? First, we are not entirely clear of the mechanical mechanism that is actually happening (i.e. what apical tissue is the most crucial to spare)- this lack of understanding probably leaves us a bit vulnerable. Second, the prostate has a very generous blood supply - there is a whole line of BPH approaches which tries to address this - PVP laser and Rezum steam therapy typically cause much less bleeding. BUT, most BPH procedures use a conductive heat source to eliminate tissue. As the name implies, we treat one area but unbeknownst to us, the heat is damaging parts of the prostate we don't see it melting in real time. Aquablation uses a water jet which is not heated - this is theoretically better since the computer only eliminates the prostate it is programmed to (like a deck pressure washer clearing of old stain). So, the question remains why do men get RE after aquablation? Because the prostate has such a good blood supply, once the pressure washer is done, one has to look back into the prostate and stop the bleeding. Like most bleeding in surgery, this is stopped with cauterization (conductive heat source). Thus about 10% of men require aggressive cautery near the apex which unintentionally damages the ejaculatory mechanism. The only BPH approaches that have Zero RE risk are mechanical, non-heat sourced approaches like: Urolift and Itind. Rezum has about a 5% RE rate in my hands because it uses convective heat (steam). The problem with Urolift and Itind and to a lesser extent Rezum is durability - because you are not eliminating all the tissue you can, sometimes the treatments only last a few years before symptoms return.

Regarding urinary symptoms after BPH procedures, this is almost universal. For whatever reason, people think surgery these days will not include pain or post op discomfort. This is patently false, modern medicine does its best to minimize these complaints but the body does takes time to heal and return to close to normal after prostate tissue is destroyed in some form (but sometimes never back to totally normal). This process typically takes 4-6 weeks but I have some patients that take up to a year for their bladder and prostate to calm down.

Finally, if you experience RE after bph surgery, can normal antegrade ejaculation ever return? Rarely, the trap door tissue grows back and normal ejaculation is restored - but this is rare in my experience - < 10% of the time. Luckily most men with changes in ejaculation still enjoy orgasm.

Best

Dr Kohler
Mayo Clinic Men's Health

Hi gentlemen,

I can comment on a few of the posts.

RE (retrograde ejaculation) or Anejaculation (no fluid at all - so men don't see the ejaculate in their urine when they void after orgasm) is sometimes an unavoidable consequence of even the most apical tissue sparing BPH approaches. The trap door that keeps the fluid from going back into the bladder is thought to be at the part of the prostate closest to the sphincter or "check valve" which attaches to the urethra. The opposite end of the prostate that connects to the bladder is thought to not be very vulnerable for either problems with ejaculation or erections.

Treatments that try to spare ejaculation essentially minimize operating on the area where the trap doors exist. Aquablation uses transrectal ultrasound in real time to 1. spare the tissue near the verumontanum (also referred to apical tissue) to leave the important tissue behind and 2. optimize depth of resection down to but ideally not through the prostate capsule. So how is it then that men could possibly lose ejaculation after aquablation? First, we are not entirely clear of the mechanical mechanism that is actually happening (i.e. what apical tissue is the most crucial to spare)- this lack of understanding probably leaves us a bit vulnerable. Second, the prostate has a very generous blood supply - there is a whole line of BPH approaches which tries to address this - PVP laser and Rezum steam therapy typically cause much less bleeding. BUT, most BPH procedures use a conductive heat source to eliminate tissue. As the name implies, we treat one area but unbeknownst to us, the heat is damaging parts of the prostate we don't see it melting in real time. Aquablation uses a water jet which is not heated - this is theoretically better since the computer only eliminates the prostate it is programmed to (like a deck pressure washer clearing of old stain). So, the question remains why do men get RE after aquablation? Because the prostate has such a good blood supply, once the pressure washer is done, one has to look back into the prostate and stop the bleeding. Like most bleeding in surgery, this is stopped with cauterization (conductive heat source). Thus about 10% of men require aggressive cautery near the apex which unintentionally damages the ejaculatory mechanism. The only BPH approaches that have Zero RE risk are mechanical, non-heat sourced approaches like: Urolift and Itind. Rezum has about a 5% RE rate in my hands because it uses convective heat (steam). The problem with Urolift and Itind and to a lesser extent Rezum is durability - because you are not eliminating all the tissue you can, sometimes the treatments only last a few years before symptoms return.

Regarding urinary symptoms after BPH procedures, this is almost universal. For whatever reason, people think surgery these days will not include pain or post op discomfort. This is patently false, modern medicine does its best to minimize these complaints but the body does takes time to heal and return to close to normal after prostate tissue is destroyed in some form (but sometimes never back to totally normal). This process typically takes 4-6 weeks but I have some patients that take up to a year for their bladder and prostate to calm down.

Finally, if you experience RE after bph surgery, can normal antegrade ejaculation ever return? Rarely, the trap door tissue grows back and normal ejaculation is restored - but this is rare in my experience - < 10% of the time. Luckily most men with changes in ejaculation still enjoy orgasm.

Best

Dr Kohler
Mayo Clinic Men's Health

I had Aquablation surgery a little over 3 months ago and I am currently experiencing retrograde ejaculation. I had my last post operation visit today and asked the doctor about my RE and she told me that the ejaculation ducts was removed in order to remove prostate tissue and that I fell into the 10% that get RE. The main reason I got the procedure because the material I read, stated that your ejaculation ducts was and observes for sexual function was supposed to be preserved. I do believe the 10% rate of this occurring is being misrepresented and the real number is much higher. My prostate size was 80 and this is not considered very large so I thought my chance of getting REWas very low. Anyone considering Aquablation think this out carefully before going forward because RE is a terrible side effect if you get it post surgery

@ken224 I am experiencing the same. I had my aquablation done 23 days ago and just found out today that I have full on RE. Like most here, I did my research and chose this method because of the low percentage who end up like this. I do have to say, other than that, this method worked very well. I have had a TURP done about 10 years ago, and if I recall correctly, the healing process was a bit more difficult. I peed out scabs for weeks, BUT, didn't get RE. Did lose about half the volume, but not ALL of it. Then, 2 years ago I tried the PAE method, that did NOTHING. I too think that the 13% is BS, after reading more articles from actual patients.

@fireman123 I think they say 13 % to have more men choose Aquablation over the other procedures. I agree with you that everything else is as advertised. The RE is the only negative and hoping with time it might pass but if not, all the other benefits outweigh that one negative.

Agreed.

But also, maybe men aren’t reporting RE to the surgeons in some cases.

I specifically told the PA prior to surgery that I chose AB to spare ejaculation and decrease risk of worsening ED and that I wanted Dr to be conservative with that tissue. I actually think she took my request as a bit of a joke. In hindsight, I should have told the Dr specifically and assertively that it was important to me to keep normal ejaculation. We are conditioned to not talk about sexual concerns even w our medical team. I hope younger generation guys are more protective of themselves. I know that I am now.

I’m 15 months past surgery. It was a success as far as most urinary issues. However I still need Gemtesa (bladder relaxant) for urgency. I still have RE. (I have read that Gemtesa might contribute to the RE issue.) Originally orgasms felt blunted, but lasted longer. It seems like orgasms have become more normal over time, but maybe I’m just getting used to the new normal.

I absolutely miss normal ejaculation. I did have a follow up procedure to inject a bulking agent into the bladder neck to resolve RE. It didn’t work, but apparently does with some guys.

I’m sorry this is kind of long and rambling. Hope it’s at least a little helpful to someone.

@fireman123 I think they say 13 % to have more men choose Aquablation over the other procedures. I agree with you that everything else is as advertised. The RE is the only negative and hoping with time it might pass but if not, all the other benefits outweigh that one negative.