Is aquablation (American Urological Association (AUA)) a recommended treatment option for benign prostatic hyperplasia (BPH)?

Aquablation in AUA Guidelines for BPH Treatment

The American Urological Association conditionally recommends Aquablation as a treatment option for benign prostatic hyperplasia in eligible patients (prostate volume 30-80g), with particular consideration for men who prioritize preservation of ejaculatory function. 1

Current AUA Guideline Status

The 2020 AUA Guideline Amendment (Guideline 22) provides an updated statement on Aquablation with supporting evidence 1:

• Recommendation strength: Conditional Recommendation
• Evidence level: Grade C
• Eligibility criteria: Prostate volume must be >30g and <80g 1
• Anesthesia requirement: General anesthesia is required (not classified as minimally invasive surgical therapy/MIST) 1

Efficacy Compared to TURP

Aquablation demonstrates comparable effectiveness to the gold standard TURP 1, 2:

• Symptom improvement: Mean IPSS reduction through 12 months is similar between Aquablation and TURP (RR 0.9 [95%CI 0.7 to 1.1]) 1
• Flow rate improvement: Maximum flow rates at 12 months are equivalent (10.3 mL/s for Aquablation vs 10.6 mL/s for TURP, p=0.86) 1
• Durability: At 36 months, IPSS improved by 50% from baseline (mean reduction of 11.0 points), with quality of life scores improving 49% from baseline 1, 2
• Sustained flow improvement: Qmax improvement exceeds 50% from 3-24 months and maintains 39% improvement at 36 months 1, 2

Safety Profile and Adverse Events

Aquablation offers specific safety advantages over TURP 1, 2:

• Lower complication rates: Fewer Clavien-Dindo grade 2 complications at 3 months (26% vs 42%, p=0.015) 1, 2
• Preserved ejaculatory function: Significantly lower retrograde ejaculation rates (6% vs 23%, p=0.002) 1, 2
• Sexual function preservation: Among sexually active men, fewer report worsening sexual function through 6 months (33% vs 56%, p=0.03) 1, 2
• Comparable transfusion risk: Blood transfusion rates are similar to TURP (very low quality evidence) 1
• Similar other complications: Bladder spasms, bleeding, dysuria, pain, and urethral damage occur at comparable rates 1

Important Limitations and Caveats

The AUA acknowledges several limitations that clinicians must discuss with patients 1:

• Less tissue removal: Prostate volume reduction is significantly less than TURP (31% vs 44%, p=0.007) 1
• Quality of life outcomes: While IPSS improves similarly, IPSS-QoL improvement was reported in 87% of Aquablation patients vs 100% in TURP patients 1
• Limited long-term data: The 2019 amendment notes that three-year data represents the same cohort, not a new study, so the conditional recommendation and Grade C evidence level remain unchanged 1
• Retreatment rates: Need for reoperation is similar to TURP but requires further long-term evaluation 1, 2

Evolution of AUA Guidance

The AUA's position on Aquablation has evolved significantly 1:

• 2003 guideline: Aquablation did not exist; emerging therapies required "additional data" before recommendation 1
• 2019 amendment: First inclusion with conditional recommendation based on initial trial data 1
• 2020 amendment: Updated supporting text for Guideline 22 with refined eligibility criteria 1

Clinical Decision Algorithm

When considering Aquablation for a BPH patient 1, 2:

1. Verify eligibility: Confirm prostate volume is 30-80g (volumes outside this range are not guideline-supported) 1
2. Assess patient priorities: Identify if ejaculatory function preservation is important (major advantage over TURP) 1, 2
3. Discuss anesthesia: Ensure patient is acceptable candidate for general anesthesia 1
4. Counsel on outcomes: Explain that symptom improvement and flow rates match TURP, but tissue removal is less 1
5. Set expectations: Discuss that retreatment rates appear similar to TURP but long-term data beyond 3 years is limited 1, 2

Key Pitfall to Avoid

Do not offer Aquablation to patients with prostate volumes >80g based on AUA guidelines 1. While research suggests efficacy in larger prostates 3, 4, 5, the AUA's conditional recommendation specifically limits eligibility to prostates <80g, and the guideline explicitly states this volume restriction 1.