Aquablation versus AEEP for BPH: Technique, Outcomes, and the Evolving Surgical Landscape - an EAU Endourology Perspective - Beyond the Abstract
In our review, we compared Aquablation and anatomical endoscopic enucleation of the prostate (AEEP), including Holmium Laser Enucleation of the Prostate (HoLEP) and other enucleation techniques. Both approaches provide substantial and durable improvements in urinary symptoms and flow rates, yet each offers distinct advantages.
AEEP remains the benchmark for long-term durability, particularly in very large prostates, with exceptionally low retreatment rates. However, its adoption is limited by a steep learning curve and a high incidence of ejaculatory dysfunction.
Aquablation offers a different approach. Through robotic planning and real-time ultrasound guidance, it provides a standardized and reproducible treatment while preserving ejaculatory function in many patients. Recent evidence, including the WATER III trial, suggests that symptom relief and safety outcomes may be more comparable to enucleation than previously appreciated.
Perhaps the most important message from the current evidence is that Aquablation and AEEP should not be viewed as competing technologies. Rather, they are complementary procedures that serve different patient priorities. For some patients, long-term durability may be the primary goal; for others, preservation of sexual function may play a greater role in treatment selection.
As BPH surgery continues to evolve, success will increasingly depend not only on procedural efficacy but also on individualized patient selection and shared decision-making. This shift toward precision BPH surgery may ultimately be the most important development in the field.
Written by: Mohammed Taher Aldoukhi, MD, Clinical Fellow, Functional, Reconstructive and Sexual Health Urology, University Health Network, University of Toronto, Toronto, Canada
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