In a man with symptomatic benign prostatic hyperplasia who is a surgical candidate, should I choose aquablation or transurethral resection of the prostate (TURP) based on prostate size, desire to preserve ejaculatory function, and bleeding risk?

Aquablation vs TURP for Benign Prostatic Hyperplasia

For men with symptomatic BPH and prostate volumes 30-80 mL who prioritize preservation of ejaculatory function, Aquablation should be the preferred choice over TURP, as it provides equivalent symptom relief with significantly lower rates of ejaculatory dysfunction (6% vs 23%) while maintaining similar safety profiles. 1

Decision Algorithm Based on Clinical Factors

Prostate Size Considerations

For prostates 30-80 mL:

• Both Aquablation and TURP provide similar symptom improvement, with IPSS reductions of approximately 11 points at 12 months 1
• Maximum flow rates improve similarly in both groups (10.3 vs 10.6 mL/s) 1
• Aquablation demonstrates superior long-term outcomes in the 50-80 mL subgroup, with significantly greater IPSS reduction maintained through 5 years (-14.1 vs -10.8, p=0.02) 2
• The 2023 European Association of Urology guidelines recognize Aquablation as providing noninferior functional outcomes to TURP for this size range 1

For prostates >80 mL:

• TURP is not the optimal choice; consider open prostatectomy, HoLEP, or bipolar enucleation instead 1
• Aquablation has shown efficacy for prostates up to 150 mL in non-comparative studies, though this exceeds guideline-supported size ranges 3, 4

For prostates <30 mL:

• Consider transurethral incision of the prostate (TUIP) as first-line, which offers lower retrograde ejaculation rates than either procedure 1

Ejaculatory Function Preservation

This is where Aquablation demonstrates clear superiority:

• Retrograde ejaculation occurs in only 6% of Aquablation patients versus 23% with TURP at 3 months (p=0.002) 1
• Among sexually active men, worsening sexual function (including ejaculatory dysfunction) occurred in 33% with Aquablation versus 56% with TURP at 6 months (p=0.03) 1
• For any sexually active patient who values preservation of ejaculatory function, Aquablation is the evidence-based choice 1
• The 5-year data confirms sustained lower rates of ejaculatory dysfunction with Aquablation (risk difference of -21.9%) 2

Bleeding Risk Assessment

The bleeding risk profile is nuanced:

• Aquablation causes a significant hemoglobin drop (mean 2.06 g/dL), but actual transfusion rates are similar between procedures 1
• One transfusion occurred in the Aquablation group versus none in TURP in the pivotal trial, though this difference was not statistically significant 1
• For patients on anticoagulation or at high bleeding risk, consider alternative procedures like HoLEP, PVP, or ThuLEP instead of either TURP or Aquablation 1
• Initial concerns about post-Aquablation bleeding have been addressed with gentle bladder-neck cautery techniques 5

Overall Safety Profile

Aquablation demonstrates fewer complications:

• Clavien-Dindo grade 2 complications occurred in 26% with Aquablation versus 42% with TURP at 3 months (p=0.015) 1
• The 5-year data shows Aquablation achieves a 23.1% lower rate of CD1P and CD2+ events 2
• Other complications (bladder spasms, dysuria, pain, urethral damage) occur at similar rates 1
• No deaths were reported in either group 1

Tissue Removal and Retreatment Rates

TURP removes more tissue but retreatment rates are similar:

• Prostate volume reduction is less with Aquablation (31%) compared to TURP (44%) at 3 months (p=0.007) 1
• Despite less tissue removal, retreatment rates are comparable: 4.3% for Aquablation versus 1.5% for TURP, though follow-up data remains limited 1
• The 5-year data shows lower surgical and medical retreatment rates with Aquablation (risk difference of -14.4% at 6 months) 2

Important Caveats and Pitfalls

Guideline strength limitations:

• The AUA provides only a Conditional Recommendation with Grade C evidence for Aquablation, reflecting that evidence comes primarily from a single randomized trial 1
• TURP remains the benchmark procedure with decades of long-term outcome data 1

Technical considerations:

• Aquablation requires general anesthesia, while TURP can be performed under spinal anesthesia 1
• Post-Aquablation hemostasis requires either electrocautery or catheter balloon traction 1
• The procedure involves robotic technology that may not be available at all centers 5

Patient selection:

• Aquablation is specifically validated for prostates 30-80 mL; use outside this range lacks robust comparative evidence 1
• Patients with obstructing middle lobes may be better served by alternative procedures 1

Quality of life outcomes:

• Both procedures provide similar improvements in quality of life scores, with no clinically meaningful difference 1
• The mean IPSS-QoL improvement is comparable between groups 1