Comparing Aquablation Therapy for Benign Prostatic Hyperplasia in 30-80 cc and 80-150 cc Prostates - Beyond the Abstract

Over the last two decades, multiple surgical modalities for BPH have been developed and adapted to account for the significant variation of prostate size.1 However, the armamentarium for larger prostates (>80 cc) is more limited and associated with increased adverse events.2,3 Indeed, open simple prostatectomy (OSP), the gold standard, is associated with ​​an increased risk of bleeding, transfusions, and longer hospitalization stay while endoscopic enucleation has a better safety profile, it has a steep learning curve that often requires fellowship training.4,5 Undeniably, there is a need for a new surgical modality that provides durable, reproducible, and safe outcomes, independent of prostate volume and surgeon experience.

Aquablation Therapy, a heat-free ablative procedure using waterjet hydrodissection, has emerged as an alternative approach to more traditional techniques.6 Aquablation therapy is the first surgeon-guided, live ultrasound image-planned and robotically-executed procedure.7 Potential benefits of the procedure are based on the use of intraoperative image guidance that allows for anatomical assessment which helps to avoid resection of the ejaculatory ducts and adjacent tissue in order to preserve sexual function.8 Anterograde ejaculatory is an essential component of overall sexual QOL and its preservation remains a major concern for many patients.9 Although procedure-related ejaculatory dysfunction in sexually active men was more frequent in WATER II (19 %) compared to W-I (11%), these rates remain markedly lower compared to other surgical modalities such as OSP (almost all patients), HoLEP (76.3%) and PVP (41.9%).10,11 This lower rate of postoperative anejaculation observed with Aquablation therapy highlights the advantages of a standardized and image guided approach. In addition, robotic systems may provide better precision, accuracy, and reproducible surgical outcomes. Indeed, the great majority of surgeons in both WATER and WATER II trials had no prior experience with the Aquablation procedure which demonstrates its short learning curve. In contrast, prostate enucleation, the only volume-independent surgical procedure for bladder outlet obstruction, is known to have a steep learning curve requiring at least 20 to 30 cases.12 As such, Aquablation may be a reasonable option for urologists inexperienced with prostate enucleation in order to avoid the need for OSP. The exceptional functional outcomes combined with the very low percentage of patients (WATER / WATER II) requiring medical (0.9% / 5.9%) or surgical retreatment (4.3% / 3.0%) at 3 years of follow-up provides promising evidence for the efficacy and durability of Aquablation therapy for small-to-moderately-sized and even large sized prostate glands.

Written by: 

  • Naeem Bhojani, MD, Division of Urological Surgery, University of Montreal, Montreal, Canada
  • Anis Assad, MD, Department of Medicine, University of Montreal, Montreal, Canada


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