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The Independence
A growing prostate and two incidents of retention motivated Duncan McEwan to seek options for his enlarged prostate. His action led him to be one of Canada’s first patients treated for benign prostatic hyperplasia with Aquablation. (Photo: Courtesy Duncan McEwan)

"You don't usually look forward to an operation, but I was excited for this one," says Duncan McEwan, recalling his feelings in the days leading up to his procedure.

Duncan would be one of Canada's first patients outside of a clinical trial to be treated with Aquablation, a system that combines image-guided technology, robotics and water to create a surgical procedure that targets the removal of prostate tissue to treat benign prostatic hyperplasia (BPH).

"Advances in technology are allowing us to provide better, faster and more precise care to more patients," says Dr. Dean Elterman, urologic surgeon, Toronto Western Hospital (TW). "I'm very excited to be able to offer different options to help our BPH patients greatly improve their quality of life."

As Duncan describes it, he started having "trouble" with his prostate about 20 years ago. It was 1998, and his recent prostate-specific antigen (PSA) test had come back high, a possible sign of cancer. He also learned that his prostate was growing in size.

Duncan's care team performed a biopsy, which came back clear of cancer, so they decided to "watch and wait," an approach that monitors a patient's prostate closely in order to determine whether cancer develops in the future and what treatment action to take.

"After a while, my physicians were pretty confident I didn't have cancer," says Duncan, who received treatment at Mount Sinai Hospital's Murray Koffler Urologic Wellness Centre. "But my prostate kept getting bigger."

Roughly 50 per cent of 50 year-old men, and 80 per cent of 80 year-old men suffer from BPH, also known as an enlarged prostate.

The condition can have a significant impact on a man's quality of life: symptoms range from a need to urinate frequently, trouble starting to urinate or not being able to urinate (urinary retention), and a weak stream. Complications such as urinary tract infections, bladder stones and chronic kidney problems can also arise.

Dean Elterman
Dr. Dean Elterman, urologic surgeon, Toronto Western Hospital, says he’s “very excited to be able to offer different options to help our BPH patients greatly improve their quality of life.” (Photo: UHN)

Duncan had learned to cope over the years with the frequent daytime visits to the bathroom and not getting adequate sleep because he was getting up several times a night. But after two incidents of urinary retention, which he knew could lead to kidney failure, he was motivated to action.

"My quality of life wasn't horrible and I had been keeping an eye on things for years wondering what to do," Duncan says. "But those two incidents were very unnerving and a bad sign, as I learned that my prostate had grown to a huge degree.

"I'm only 65 and knew it could only get worse. I wanted to do something about it."

In 2018, he discussed possible treatments with his urologist who said that surgically removing a large portion of Duncan's prostate was an option – though the surgeon was reluctant to do so.

Duncan was then referred to Dr. Elterman who, since joining TW's urology team in 2012, has built the department's capacity to provide advanced treatments in urological surgery for benign prostate enlargement – one of few centres in Canada to do so.

At the time, Dr. Elterman recommended treating Duncan's prostate with the GreenLight Laser, a minimally invasive surgical procedure that also treats BPH. TW is the only academic teaching hospital in Toronto to provide this treatment. Duncan decided to think about it.

After some thought, he returned to Dr. Elterman for further discussion and, by this time, the surgeon was finishing a clinical trial to test the safety and efficiency of Aquablation. In fact, Toronto Western Hospital has the first and only Aquabeam system that performs Aquablation in Canada.

Aquablation procedure
In this still image, a resection zone of prostate tissue to be removed is mapped out with a green dotted line using ultrasound technology. The surgeon then engages the robot to release a water jet that acts as a powerful windshield wiper that sweeps through the tissue very quickly. (Photo: PROCEPT BioRobotics)

With his relatively young age and large prostate, Duncan was the perfect candidate for the procedure and was scheduled as one of the first four patients in Canada to receive the treatment in May 2019.

Aquablation is quick and, as far as surgery goes, pretty easy.

"The system itself ensures precision in the procedure and equalizes surgical skill," explains Dr. Elterman. "Although I plan and map how much of the prostate needs to be removed, a robotic system, controlled by the surgeon at all times, executes it at the push of a pedal."

"Our clinical trial showed that the outcomes for patients when using Aquablation were the same, regardless of the level of experience or expertise of the surgical team."

They are also achieved quickly as Aquablation uses a high-velocity stream of water to remove the prostate tissue, which can be done in less than 10 minutes no matter how big the prostate. Dr. Elterman describes it as "a really powerful windshield wiper that sweeps through the tissue very quickly, following an individualized plan for each man's prostate."

The first week after the procedure was a little difficult but, within three weeks, Duncan says things just kept improving. He now only gets up once at night to use the bathroom and has seen his overall quality of life improve. The excitement he felt before surgery was justified.

"I just feel better." 


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