What is aqua ablation (Aqua Ablation)?

Aquablation: A Robotic Waterjet Therapy for BPH

Aquablation is a robotic-assisted surgical procedure that uses high-velocity water jets to remove prostate tissue in patients with benign prostatic hyperplasia (BPH), providing similar symptom improvement to transurethral resection of the prostate (TURP) with fewer sexual side effects. 1

Procedure Components and Technique

Aquablation (also called AquaBeam) consists of:

• A robotic handpiece, console, and conformal planning unit (CPU)
• High-velocity water jet technology for non-thermal ablation of obstructing prostatic tissue
• Real-time transrectal ultrasound imaging for precise targeting
• General anesthesia requirement (not classified as a minimally invasive surgical therapy) 2

The procedure involves:

1. Transurethral placement of the robotic handpiece
2. Water jet ablation of prostate tissue under ultrasound guidance
3. Hemostasis achieved via electrocautery or traction from a 3-way catheter balloon 2

Efficacy and Outcomes

Aquablation has demonstrated:

• Noninferior functional outcomes compared to TURP in patients with LUTS and prostate volumes between 30-80 ml 2
• Sustained improvements in International Prostate Symptom Score (IPSS), quality of life (QoL), and maximum flow rate (Qmax) through 36 months 2
• At 36 months, mean IPSS improvement of 11.0 points (50% from baseline) and QoL improvement of 49% from baseline 2
• Similar maximum flow rate improvements compared to TURP at 12 months (10.3 vs. 10.6 mL/s) 2

Advantages Compared to TURP

• Fewer Clavien-Dindo grade 2 complications at 3 months (26% vs. 42%, p=0.015) 2
• Significantly lower rates of retrograde ejaculation (6% vs. 23%, p=0.002) 2
• Less sexual dysfunction (33% vs. 56% reporting worsening sexual function at 6 months, p=0.03) 2
• Better preservation of erectile and ejaculatory function 2, 3

Limitations and Considerations

• Less reduction in prostate volume at 3 months compared to TURP (31% vs. 44%, p=0.007) 2
• Higher retreatment rates compared to simple prostatectomy (SP) for large prostates >80g 4
• Eligibility dependent on prostate volume (30-80g optimal range) 2
• Concerns about optimal methods for achieving post-treatment hemostasis 2
• Significant hemoglobin drop (2.06 g/dl) reported, though transfusion need is low 2

Clinical Applications

Aquablation is particularly suitable for:

• Men with moderate-to-severe LUTS due to BPH with prostate volumes between 30-80 ml 2
• Patients who prioritize preservation of sexual function 2, 3
• Those seeking alternatives to traditional TURP with similar efficacy but fewer sexual side effects 1

Guidelines and Recommendations

The American Urological Association (AUA) has given Aquablation a Conditional Recommendation with Evidence Level Grade C 2, positioning it as one of several surgical options for BPH treatment.

The European Association of Urology notes that Aquablation provides noninferior functional outcomes compared with TURP in patients with LUTS and prostate volumes between 30-80 ml 2.

Emerging Evidence

Recent studies suggest Aquablation can be used for larger prostates (80-150 ml) with similar symptom improvement as seen in smaller prostates, though with an expected increase in complication risk 5.

When compared with simple prostatectomy for prostates >80g, Aquablation shows advantages in reduced blood transfusions, shorter hospital stays, and shorter operative times, but has higher retreatment rates and less improvement in IPSS scores at 1-year follow-up 4.