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Aquablation — AquaBeam Robotic Waterjet for BPH

Aquablation (AquaBeam Robotic System; Procept BioRobotics) is the first surgical BPH therapy to combine real-time transrectal ultrasound guidance with robotically executed, heat-free, high-velocity saline waterjet ablation of the prostatic adenoma.[1][2][3] Within the BPH treatment ladder, Aquablation is unique: a resective procedure (TURP-equivalent or superior IPSS / Qmax improvements) with MIST-level sexual-function preservation (antegrade ejaculation in 72–99.6%), efficacy that is size-independent across 30–150+ mL, and a shorter learning curve than HoLEP / AEEP. For positioning vs other BPH options see BPH & Male LUTS — chooser.

Mechanism of action​

The AquaBeam delivers a high-velocity saline jet (500–8,000 PSI) through a robotically controlled handpiece. The procedure has two phases[1]:

  1. Cutting mode. Surgeon maps the treatment contour on real-time TRUS — defining angle, length, depth, and contour. The console executes the ablation automatically using the high-pressure waterjet.
  2. Coagulation mode. Low-pressure saline (5–15 PSI) plus a 2 W green-light laser (532 nm) for cauterization after resection.

The waterjet preferentially ablates adenomatous tissue while preserving collagenous structures — the surgical capsule, bladder neck, and blood vessels. Because ablation is heat-free, there is no thermal injury to surrounding neurovascular structures.[1][2][4]

A defining technical feature is the surgeon's ability to define a "veru-protection zone" in the treatment plan, sparing the verumontanum and ejaculatory ducts — the mechanism behind Aquablation's superior ejaculatory-function preservation.[4][5]

Procedure​

Performed under general or regional anesthesia in the OR[1][6]:

  1. Custom 22 Fr rigid cystoscope introduced under direct vision.
  2. AquaBeam handpiece advanced; 15 mL balloon inflated against the bladder neck.
  3. TRUS performed; surgeon maps prostate contour and resection zone on the conformal planning unit (CPU).
  4. Robotic system executes ablation automatically per plan.
  5. Mean total OR time 33–37 min; mean resection time 4–8 min (vs TURP resection 27 min, p < 0.001).[3][7]
  6. Three-way Foley placed for hemostasis; median catheterization 1–2 days.
  7. Mean LOS 1.6 days; most discharged POD 1.[6][7]

Single vs multi-pass​

A multi-pass (≥ 2 passes) protocol yields lower IPSS by ~ 4 points and higher Qmax by ~ 5 mL/s at 24–36 months vs single pass — independent of prostate volume — without increasing ejaculatory dysfunction.[8]

Patient selection​

Based on the WATER and WATER II pivotal trials and the AUA 2023 Guideline Amendment[3][9][10]:

  • Age 45–80 years
  • Moderate-to-severe LUTS (IPSS ≥ 12)
  • Prostate volume 30–150 mL FDA-cleared; real-world use extends well beyond — a 70,270-case global database had mean prostate volume 87.3 mL with maximum 1,189 mL.[11]
  • Treats obstructive median lobes — a meaningful advantage over UroLift and iTIND. Subgroup analysis showed larger IPSS improvements in men with enlarged middle lobes and severe middle-lobe obstruction.[12]
  • Requires general or regional anesthesia (unlike office-based MISTs).
  • AUA 2023: Conditional Recommendation, Grade C evidence, 30–80 mL; may also be offered for prostates > 80 mL based on WATER II.[10]

Clinical efficacy​

WATER — pivotal RCT vs TURP (30–80 mL)​

181 men randomized to Aquablation vs TURP[3][13]:

  • Noninferiority met for IPSS reduction at 6 months.
  • Safety superiority (Clavien-Dindo persistent grade 1 or ≥ 2): 26% vs 42% (p = 0.015).
  • 5-yr maintained IPSS / Qmax / safety profile.

WATER II — large prostates (80–150 mL)​

101-pt single-arm prospective[9]:

TimepointIPSSQmax (mL/s)Freedom from retreatment
Baseline22.68.6—
12 mo6.2 (−17.0)21.1 (+12.5)100%
36 mo6.5 (−16.3)18.5 (+9.8)97%
5 yr6.8 (−15.9)17.1 (+9.2)96.3%

A 100-mL prespecified subgroup analysis showed no efficacy difference through 5 years — confirming size-independent outcomes.

WATER vs WATER II 5-yr comparison​

Outcomes were remarkably consistent regardless of size[14]:

OutcomeWATER (30–80 mL)WATER II (80–150 mL)p
IPSS at 5 yr7.06.80.85
Qmax at 5 yr17.317.1 mL/s0.93
BPH-medication-free99%94%0.05
Freedom from surgical retreatment95%97%0.51

WATER III — vs laser enucleation (80–180 mL)​

202 men prospective partially randomized noninferiority[15]:

  • IPSS improvement 3 mo: −12.9 (Aquablation) vs −13.1 (LEP) — noninferiority probability > 0.999.
  • Clavien-Dindo ≥ 2 / persistent ≥ 1: 40.8% vs 56.8%.
  • Retrograde ejaculation: 14.8% vs 77.1% (p < 0.001).

Pooled 5-study analysis​

WATER + WATER II + OPEN WATER + FRANCAIS WATER + JAPAN PMS — mean prostate volume 71.7 mL (range 20–242 mL); IPSS 21.5 → 6.6 at 12 mo; Qmax 8.1 → 20.5; PVR 105.9 → 53.1.[16]

Largest single-center real-world (4-yr)​

330 patients[17]:

  • Mean prostate volume 110.3 mL (range 38–330 mL).
  • IPSS 23.8 → 6.9 at 4 yr.
  • Qmax 6.4 → 17.4 at 4 yr.
  • Volume reduction −41.3% at 1 yr.
  • Antegrade ejaculation preserved in 99.6% of men.
  • 3.3% required transfusion; 3.0% required TURP for residual anterior tissue.

Sexual function preservation​

Among Aquablation's most important differentiators from TURP and enucleation[5][18][19]:

  • Bettencourt 2025 SR (15 studies / 1,533 patients): antegrade-ejaculation preservation 72–99.6%.[18]
  • WATER: anejaculation 10% (Aquablation) vs 36% (TURP) at 12 mo (p = 0.0003); maintained through 5 yr.[3][18]
  • WATER III: retrograde ejaculation 14.8% vs 77.1% (LEP), p < 0.001.[15]
  • Prospective comparative (Perez 2025): ejaculatory function preserved in 82.8% Aquablation vs 36% TURP vs 18% HoLEP.[19]
  • Erectile function stable across studies — no de novo ED reported.[18][20]

Mechanism: surgeon-defined "veru-protection zone" during treatment planning preserves the verumontanum and ejaculatory ducts.[4][21]

Safety profile and bleeding​

WATER demonstrated safety superiority over TURP (26% vs 42% Clavien-Dindo persistent grade 1 / ≥ 2, p = 0.015).[3] No late procedure-related AEs after month 6.[13] De novo incontinence 2% at 12 mo in WATER II.[6]

Bleeding is the principal historical safety concern.

  • WATER II (large prostates): 10% transfusion at 12 mo, 5% takeback fulguration.[6]
  • Bitar 2025 BJU Int real-world (n = 70,270 procedures, 2019–2024, Asia / Europe / North America): overall transfusion or return to OR for hemostatic fulguration 0.2% — bleeding risk has decreased substantially with experience and technique refinement.[11]
  • Complication rates declined significantly after the first 30 cases in a prospective comparative study, consistent with the learning curve.[19]

Learning curve​

Aquablation has a notably shorter learning curve than HoLEP / AEEP[10][21]:

  • Trifecta (operative time < 60 min, Clavien-Dindo grade ≤ 2, 6-mo IPSS Δ ≥ 10) achieved by case 30.
  • HoLEP / AEEP typically requires 50–200 cases for proficiency.[10]

Retreatment and durability​

Aquablation has among the lowest retreatment rates of any MIST:

SourcePopulationFreedom from surgical retreatment
WATER (30–80 mL)5 yr95%
WATER II (80–150 mL)5 yr96.3–97%
Real-world n = 3304 yr96.1%
Shin 2024 BJU Int NMA12 mo reintervention NMA[22]Ranked 2nd, behind TURP only
Akgul 2025 SR5 yr[23]4.4–6% surgical retreatment

For comparison: UroLift ~ 22% real-world 5-yr retreatment, Rezūm ~ 4.4%, Optilume BPH 67.5% remained symptomatic responders at 2 yr (no > 2 yr data), PAE 13–21% at 24 mo. AEEP / HoLEP remains the gold standard for durability at 1–2% long-term.[10]

Aquablation vs AEEP (HoLEP) — key trade-offs​

The 2026 EAU Endourology perspective summarizes[10]:

ParameterAquablationAEEP / HoLEP
Prostate size range30–150+ mLAny size
Learning curve~ 30–50 cases~ 50–200 cases
5-yr surgical retreatment3–8%1–2%
Ejaculatory preservation72–99.6%18–23%
Stress incontinence0–2%5–9.3%
AnesthesiaGeneral / regionalGeneral / regional
Tissue for pathologyYesYes

Comparison with other MISTs​

ProcedureIPSS Δ (12 mo)Qmax Δ (12 mo)Volume rangeMedian lobe5-yr retreatment
Aquablation−15.1+10.3 mL/s30–150+ mLTreatable~ 4%
TURP−15.1+10.6up to 80 mLTreatableLowest
HoLEPsimilar to TURPsimilar to TURPAny sizeTreatable1–2%
Optilume BPH−11.5+10.320–80 mLExcludednot yet 5-yr
Rezūm−11.3+5.630–80 mLTreatable4.4%
UroLift−11.1+4.030–80 mL (≤ 100 RW); MedLift for OMLTreatable with MedLift~ 22%
iTIND−9.3 (RCT)+3.525–75 mLExcludedHigh per Italian Delphi
PAE−11.6 to −14.5+6.1Any sizeTreatable13–21% at 2 yr

Emerging applications​

Aquablation in localized prostate cancer with concurrent LUTS — a prospective study showed Aquablation improved urinary function, preserved sexual function, and caused only a transient spike in circulating tumor cells (< 1 mo to baseline) without adverse oncologic outcomes at intermediate follow-up.[24]

Where Aquablation fits​

A resective procedure with MIST-level sexual-function preservation — TURP-equivalent or superior IPSS / Qmax improvements across all prostate sizes while preserving ejaculatory function in the vast majority. Distinguishing advantages:

  • Size-independent efficacy — only MIST that effectively treats both 30–80 mL and 80–150+ mL prostates from a single playbook.
  • TURP-equivalent Qmax improvement without TURP's anejaculation rate.
  • Treats obstructive median lobes without device modification.
  • Low retreatment (~ 4% at 5 yr) — among the best of any MIST.
  • Shorter learning curve than HoLEP / AEEP.

Limitations vs HoLEP: slightly higher long-term retreatment (3–8% vs 1–2%); requires the AquaBeam robotic system. Limitations vs office-based MISTs (UroLift / Rezūm / iTIND / Optilume BPH): general or regional anesthesia and OR setting required. Bleeding remains the principal complication tracked, though modern real-world rates have dropped to ~ 0.2% transfusion / takeback fulguration in a 70,270-case database.[11]

See also​

BPH & Male LUTS — chooser · Prostate Enucleation / HoLEP · Simple Prostatectomy · Optilume BPH · Rezūm · iTIND · UroLift PUL · Prostate Artery Embolization

References​

1. Hwang EC, Jung JH, Borofsky M, Kim MH, Dahm P. Aquablation of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev. 2019;2:CD013143. doi:10.1002/14651858.CD013143.pub2

2. Petrus Vermeulen L, Ordones FV, Zarrabi AD, Gilling PJ. Making waves: an update on Aquablation. Urol Clin North Am. 2025;52(4):535-545. doi:10.1016/j.ucl.2025.07.009

3. Gilling P, Barber N, Bidair M, et al. WATER: a double-blind, randomized, controlled trial of Aquablation vs transurethral resection of the prostate in benign prostatic hyperplasia. J Urol. 2018;199(5):1252-1261. doi:10.1016/j.juro.2017.12.065

4. Mykoniatis I, Renterghem KV, Sokolakis I. How can we preserve sexual function after ablative surgery for benign prostatic hyperplasia? Curr Drug Targets. 2021;22(1):4-13. doi:10.2174/1389450121666200925143916

5. Albayrak AT, Bulbul MV, Rubez A, Fregonesi A, Serefoglu EC. Sexual and urinary outcomes of minimally invasive surgical therapies for LUTS/BPH: a narrative review. Int J Impot Res. 2026. doi:10.1038/s41443-026-01271-2

6. Bhojani N, Bidair M, Zorn KC, et al. Aquablation for benign prostatic hyperplasia in large prostates (80-150 cc): 1-year results. Urology. 2019;129:1-7. doi:10.1016/j.urology.2019.04.029

7. Gilling P, Reuther R, Kahokehr A, Fraundorfer M. Aquablation — image-guided robot-assisted waterjet ablation of the prostate: initial clinical experience. BJU Int. 2016;117(6):923-929. doi:10.1111/bju.13358

8. Bach T, Barber N, Elterman D, et al. Aquablation outcomes in men with LUTS due to BPH following single versus multi-pass treatments. Urology. 2022;169:167-172. doi:10.1016/j.urology.2022.07.007

9. Bhojani N, Bidair M, Kramolowsky E, et al. Aquablation therapy in large prostates (80-150 mL) for lower urinary tract symptoms due to benign prostatic hyperplasia: final WATER II 5-year clinical trial results. J Urol. 2023;210(1):143-153. doi:10.1097/JU.0000000000003483

10. Aldoukhi MT, Polo J, Siqueira MHB, et al. Aquablation versus AEEP for BPH: technique, outcomes, and the evolving surgical landscape — an EAU Endourology perspective. World J Urol. 2026;44(1):330. doi:10.1007/s00345-026-06431-z

11. Bitar M, Ferreira R, Shprits S, et al. Aquablation for benign prostatic hyperplasia: real-world prostate size relevance and bleeding events across 6 years. BJU Int. 2025. doi:10.1111/bju.70118

12. Plante M, Gilling P, Barber N, et al. Symptom relief and anejaculation after Aquablation or transurethral resection of the prostate: subgroup analysis from a blinded randomized trial. BJU Int. 2019;123(4):651-660. doi:10.1111/bju.14426

13. Gilling PJ, Barber N, Bidair M, et al. Randomized controlled trial of Aquablation versus transurethral resection of the prostate in benign prostatic hyperplasia: one-year outcomes. Urology. 2019;125:169-173. doi:10.1016/j.urology.2018.12.002

14. Berjaoui MB, Nguyen DD, Almousa S, et al. WATER versus WATER II 5-year update: comparing Aquablation therapy for benign prostatic hyperplasia in 30–80-cm³ and 80–150-cm³ prostates. BJUI Compass. 2024;5(11):1023-1033. doi:10.1002/bco2.430

15. Ritter M, Stein J, Barber N, et al. WATER III: a prospective, partially randomized trial of Aquablation therapy versus transurethral laser enucleation of the prostate for treatment of lower urinary tract symptoms. Eur Urol Focus. 2026;12(2):266-274. doi:10.1016/j.euf.2026.01.006

16. Siqueira MHB, Berjaoui MB, Bhojani N, et al. Outcomes of Aquablation: pooled analysis from the WATER, WATER II, OPEN WATER, FRANCAIS WATER, and JAPAN PMS studies. World J Urol. 2025;43(1):635. doi:10.1007/s00345-025-06033-1

17. Omidele OO, Siegal AS, Roshandel R, Te AE, Kaplan SA. Aquablation at 4-years: real world data from the largest single-center study with associated outcomes follow-up. Urology. 2024;194:216-220. doi:10.1016/j.urology.2024.07.047

18. Bettencourt A, Wu J, Borrell JA, et al. Ejaculatory function after robotic waterjet ablation for the treatment of benign prostatic hyperplasia: a systematic review. Int J Impot Res. 2025. doi:10.1038/s41443-025-01087-6

19. Perez D, Mamber A, Pasherstnik M, et al. Aquablation for benign prostatic hyperplasia: a prospective study with comparative analysis of transurethral resection of the prostate and holmium laser enucleation. J Laparoendosc Adv Surg Tech A. 2025. doi:10.1177/10926429251393894

20. Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA Guideline Amendment 2023. J Urol. 2024;211(1):11-19. doi:10.1097/JU.0000000000003698

21. El Hajj A, Misrai V, Nasrallah AA, et al. Learning curve in Aquablation: an international multicenter study. World J Urol. 2022;40(3):773-779. doi:10.1007/s00345-021-03898-w

22. Shin BNH, Qu L, Rhee H, Chung E. Systematic review and network meta-analysis of re-intervention rates of new surgical interventions for benign prostatic hyperplasia. BJU Int. 2024;134(2):155-165. doi:10.1111/bju.16304

23. Akgul B, Tozsin A, Aydın A, et al. Reintervention rates after minimally invasive benign prostatic hyperplasia therapies: a systematic review including industry involvement. World J Urol. 2025;43(1):494. doi:10.1007/s00345-025-05884-y

24. Teoh JYC, Yuen SKK, Lau BSY, et al. Robotic waterjet resection for men with prostate cancer suffering from lower urinary tract symptoms. Urology. 2025;198:153-157. doi:10.1016/j.urology.2025.01.020