What is Aquablation?
Aquablation is an image-guided robotic waterjet ablation therapy (AquaBeam system) that uses a high-velocity waterjet combined with real-time ultrasound imaging to precisely remove prostate tissue in men with benign prostatic hyperplasia (BPH). 1
How It Works
The procedure employs robotically controlled, heat-free resection that allows for targeted removal of enlarged prostate tissue while preserving surrounding structures, particularly the sphincter mechanism 2, 3. The key technical elements include:
- Real-time ultrasound guidance for precise tissue mapping
- High-velocity waterjet for tissue ablation (no thermal energy)
- Robotic assistance for controlled, reproducible tissue removal
- Post-procedure gentle bladder-neck cautery for hemostasis 4
Clinical Indications and Eligibility
Aquablation is appropriate for prostates between 30-80 mL according to current guidelines 5, though real-world data demonstrates consistent use across a much broader range of prostate sizes, including very large glands up to 1189 mL 6. The 2023 European Association of Urology guidelines classify it as an alternative ablative technique for patients with lower urinary tract symptoms (LUTS) and prostate volumes in the 30-80 mL range 1.
Efficacy Compared to Standard Treatments
Functional Outcomes
Aquablation provides noninferior functional outcomes compared to TURP (transurethral resection of the prostate) during mid-term follow-up 1. Recent prospective data shows Aquablation achieves the greatest IPSS improvement (18.9 points) compared to TURP (13.8 points) and HoLEP (14.7 points) 7.
Sexual Function Preservation
The most significant advantage of Aquablation is superior preservation of ejaculatory function 1:
- Ejaculatory dysfunction rate: 10% with Aquablation vs. 36% with TURP 1
- 82.8% ejaculatory function preservation compared to 36% with TURP and 18% with HoLEP 7
- Erectile function is well-preserved (comparable to baseline) 2, 7
Safety Profile and Complications
Bleeding Concerns
Bleeding is the principal perioperative concern with Aquablation, though life-threatening events are rare 2:
- Transfusion required in 1-8% of cases, more frequently in larger prostates 2
- Overall rate of transfusion or return to OR for bleeding control: 0.2% in real-world data of 70,270 procedures 6
- Significant hemoglobin drop (2.06 g/dL) reported, but transfusion need remains low 1
- Initial hemostasis concerns have been successfully addressed with gentle bladder-neck cautery 4
Overall Complication Profile
Most complications are minor (Clavien-Dindo grade 1-2) 2:
- Fewer overall complications than TURP (26% vs 42%) 1
- Severe complications (grade ≥3) are uncommon, usually related to bleeding or urinary retention 2
- Long-term sequelae (strictures, bladder neck contracture) are rare 2
- Complication rates decline significantly after the first 30 cases, indicating a manageable learning curve 7
Retreatment Rates
Retreatment rates are slightly higher with Aquablation compared to TURP 1:
- Aquablation: 4.3% retreatment rate
- TURP: 1.5% retreatment rate
However, when compared to simple prostatectomy for larger prostates (>80 mL), Aquablation shows higher retreatment rates and greater reliance on postoperative alpha-blockers 8.
Practical Considerations
Advantages
- Shorter hospital stay and catheterization time compared to traditional surgery
- Efficient procedure with reproducible results
- Effective across all prostate sizes in real-world practice 6
- Superior sexual function preservation makes it ideal for sexually active men 1, 2
Limitations
- Requires specialized equipment and training
- Learning curve exists, though shorter than HoLEP 7
- Slightly higher retreatment rates than TURP
- Bleeding management requires attention to technique
Current Guideline Status
The 2020 AUA guidelines include Aquablation with updated supporting text 5, while the 2023 EAU guidelines classify it as an alternative ablative technique but note ongoing concerns about optimal hemostasis methods 1. The procedure is increasingly recognized as a valid alternative to standard resection techniques with excellent long-term functional outcomes 4.