1. My Clinical Approach to Aquablation
More and more patients with benign prostatic hyperplasia ask me about Aquablation, having read marketing material that presents it either as a “robot that operates by itself” or as a risk-free solution. The reality is more balanced.
Aquablation is a genuinely valuable, guideline-supported option for specific patients — not for everyone. My role is to explain what the WATER and WATER II trials actually show, without exaggeration in either direction.
In practice, I always:
- Exclude prostate cancer before any procedure for BPH.
- Obtain an accurate prostate volume assessment before discussing indications.
- Present all alternatives (TURP, HoLEP, Rezūm, laparoscopic adenomectomy) with their real-world data.
- Give clear information on possible complications, not only on the advantages.
This guide is based on the 2026 EAU Guidelines on Male LUTS and the published WATER/WATER II trial data — not on manufacturer marketing material.
2. What Is Aquablation
Aquablation is performed transurethrally, without any external incision. It uses a high-velocity saline waterjet to remove obstructing adenomatous tissue.
- The surgeon assesses the anatomy with real-time ultrasound imaging and plans the area of tissue to be removed.
- Execution of the waterjet ablation is carried out under robotic guidance, following the approved plan.
- The goal is removal of the tissue causing urethral obstruction.
The waterjet ablation of prostate tissue itself is performed without thermal energy. For haemostasis at the end of the procedure, balloon catheter tamponade may be used, or — if needed — electrocautery or low-power laser, depending on the surgical finding.
3. Is Aquablation a Robotic Procedure?
A robotically controlled system is indeed used to execute the planned waterjet treatment. However:
- The surgeon plans and supervises the entire treatment in real time.
- The system does not make autonomous treatment decisions.
- It is not the same technology as da Vinci robotic surgery, which is used for other procedures (e.g. robotic prostatectomy).
This distinction matters so that Aquablation is not confused with robotic/laparoscopic surgery for other conditions.
4. How the Procedure Works
Endoscopic access
The system is introduced through the urethra, without any external incision.
Prostate imaging
The surgeon assesses the anatomy and the area causing obstruction, using real-time ultrasound imaging.
Treatment planning
The tissue to be removed is precisely defined, based on the individual patient’s anatomy.
Waterjet ablation
Tissue is removed with a controlled, high-velocity saline waterjet, without thermal energy at this stage.
Haemostasis
Appropriate bleeding control is performed at the end of the procedure, according to the surgical finding (e.g. balloon catheter tamponade, electrocautery, or laser where needed).
Catheter placement
A urinary catheter is placed for as long as the surgeon considers necessary.
The exact course varies per patient, depending on anatomy, prostate size, and the surgical finding.
5. Who Is a Candidate & What Prostate Size Is Treatable
Aquablation is intended for men with benign prostatic hyperplasia and moderate-to-severe lower urinary tract symptoms (LUTS) that are not adequately controlled with conservative management or medical therapy, or who have a clear surgical indication. Typical symptoms include:
Weak urinary stream
Difficulty starting urination
Intermittent stream
Incomplete emptying
Frequency / nocturia
Recurrent urinary retention
Significant obstruction
Aquablation is not a suitable choice for every case of BPH — suitability is individualised.
What Prostate Size Can Be Treated?
According to the 2026 EAU guidelines, the strong recommendation applies to glands of 30–80 mL, especially in patients interested in preserving ejaculation. For glands of 80–150 mL, the WATER II trial showed the method to be feasible, with significant symptom improvement at 12 months — however the guidelines explicitly state that further randomised trials are needed before this becomes an equally strong recommendation.
It should not be assumed that every very large prostate is automatically ideal for Aquablation — in the 80–150 mL range, a higher rate of bleeding-related events was also observed compared with smaller glands (see Disadvantages section).
Aquablation & the Median Lobe
The technique can be adapted to each patient\u2019s specific prostate anatomy, since the surgeon individually plans the treatment area based on ultrasound imaging — including selected cases with an obstructing median lobe. Final suitability is always assessed by the surgeon, based on the specific anatomy.
6. Pre-operative Evaluation
Depending on the case, pre-operative evaluation may include:
Detailed history
IPSS (symptom questionnaire), where used
Uroflowmetry
Post-void residual measurement
PSA
Digital rectal examination
Prostate ultrasound & volume assessment
Urinalysis / urine culture
Renal function assessment
Blood tests
Assessment of anticoagulants/antiplatelets
Cystoscopy, where indicated
Not every test is needed for every patient — the evaluation is individualised.
7. Anaesthesia & Procedure Duration
Anaesthesia
The procedure is performed in a surgical setting and can be done under appropriate anaesthesia (general or spinal), depending on the case, the anaesthetic assessment, and the surgical centre\u2019s protocol.
Duration
In the WATER trial, the waterjet ablation step itself was significantly shorter than the equivalent resection step in TURP (about 4 minutes vs 27 minutes). However, total operating time was similar between the two techniques (about 33 vs 36 minutes), since it also includes other steps (access, mapping, haemostasis, catheter placement).
Total operating time should not be confused with the duration of the waterjet ablation itself.
8. Catheter & Hospital Stay
Is a Catheter Needed After Aquablation?
Yes, a temporary urinary catheter is typically used after the procedure. In many cases early removal (within the first few days) is achievable, but the exact duration depends on prostate size, haemostasis, voiding, the centre\u2019s protocol, and the individual patient\u2019s course — there is no single universal duration for everyone.
Hospital Stay
Length of hospital stay varies by patient and by surgical centre, depending on the clinical protocol and each patient\u2019s course.
9. Recovery
In the first days after the procedure, some temporary discomfort is possible:
Haematuria
Frequency
Urgency
Mild burning on urination
Small clots
Temporary irritation
These symptoms usually improve gradually. General guidance includes adequate hydration where allowed, avoiding strenuous physical activity for the period recommended by the surgeon, and attending scheduled follow-up.
When Does Urination Improve?
Many patients notice relatively early improvement, but there may initially be temporary irritation, and the final functional outcome develops over time. The course is not the same for every patient.
10. Advantages
- Effective improvement of symptoms and urinary flow, non-inferior to TURP in a randomised trial.
- Individualised, image-guided treatment planning based on prostate anatomy.
- Tissue removal via a mechanism without thermal energy during the ablation itself.
- Possibly lower rate of ejaculatory dysfunction in selected comparisons with conventional TURP.
- Can be applied to larger glands, based on specific feasibility data (WATER II).
None of the above is a guaranteed outcome for every patient.
11. Disadvantages & Limitations
- Possible bleeding / haematuria, requiring haemostasis at the end of the procedure.
- Possible, rare, need for blood transfusion — more frequent in larger glands (WATER II).
- Possible urinary retention.
- Possible urinary tract infection.
- Temporary irritative symptoms (frequency, burning).
- Possible need for a repeat procedure in the future — in the WATER trial, retreatment at 5 years was 5.1% after Aquablation vs 1.5% after TURP.
- Not the best option for every patient.
- Requires specialised equipment and a trained surgical team.
- Availability and cost vary by surgical centre.
12. Does Aquablation Affect Ejaculation?
In a randomised clinical trial (WATER), among sexually active men, the anejaculation rate was lower after Aquablation than after TURP (~10% vs ~36%).
This means Aquablation may offer a higher chance of preserving ejaculation compared with some traditional resection procedures — it does not mean ejaculation is preserved in everyone. The risk depends on anatomy, technique, and the extent of treatment, and retrograde ejaculation or anejaculation can still occur.
In 80–150 mL glands (WATER II trial), preservation of antegrade ejaculation was slightly lower (~81%) compared with the smaller glands in the original WATER trial (~90%).
13. Aquablation & Erectile Function
Available data do not show a significant deterioration of erectile function in most patients. However, there is no absolute guarantee of zero risk — erectile function also depends on many other factors (age, cardiovascular health, medications, psychological factors).
14. Aquablation vs TURP
| Feature | Aquablation | TURP / TURiS |
|---|---|---|
| Tissue removal mechanism | Mechanical waterjet ablation | Electrosurgical resection |
| Thermal energy during removal | No | Yes |
| Track record / clinical experience | Newer technique, shorter track record | Decades of clinical experience |
| Effectiveness for LUTS | Non-inferior to TURP (WATER trial) | Established reference standard |
| Size indication | 30–80 mL (EAU strong recommendation) | 30–80 mL (established range) |
| Anejaculation rate | ~10% | ~36% |
| Retreatment at 5 years | 5.1% | 1.5% |
| Availability | Requires specialised equipment | Widely available |
The choice depends on prostate size and anatomy, patient priorities, and the surgical centre\u2019s experience. TURiS/bipolar TURP remains a widely available, well-established procedure at our practice as well.
15. Aquablation vs HoLEP
| Feature | Aquablation | HoLEP |
|---|---|---|
| Mechanism | Mechanical waterjet ablation | Laser enucleation (Ho:YAG) |
| Qmax improvement | Significant improvement | Greater on average (+3.24 mL/s) |
| PVR reduction | Significant improvement | Greater on average (−23 mL) |
| Incontinence risk | Lower | Higher (relative risk ~4.5x) |
| Transfusion risk | Higher | Lower |
| Use in very large glands | Feasibility data (80–150 mL) | Established option for very large glands |
| Learning curve | Standardised planning | Requires specialised surgical training |
Neither method is universally superior — the choice is individualised based on prostate size, anatomy, and the centre\u2019s experience.
16. Aquablation vs Rez\u016bm & UroLift
Aquablation vs Rez\u016bm
Rez\u016bm and Aquablation are not simply two variants of the same procedure:
Rez\u016bm
A minimally invasive water-vapour (thermal energy) treatment, with gradual tissue response over time.
Aquablation
Immediate mechanical tissue removal with a high-velocity saline waterjet, without thermal energy during the removal step.
They differ in invasiveness, type of anaesthesia, catheter needs, speed of symptom relief, prostate-size indications, and likelihood of retreatment.
Aquablation vs UroLift
UroLift does not remove prostate tissue — it works with permanent implants that mechanically compress the prostate lobes. Aquablation, in contrast, actually removes the obstructing tissue. These are fundamentally different approaches with different indications.
17. Tissue for Pathology
Tissue can be collected during Aquablation for pathological examination; however, it should not be assumed that the specimen has the same quality or volume as specimens obtained during TURP or HoLEP. The need for and adequacy of tissue sampling is assessed by the surgeon on a case-by-case basis.
18. Aquablation & Prostate Cancer
Aquablation is a treatment for benign obstruction due to BPH, and not a treatment for prostate cancer.
Before the procedure, appropriate evaluation for possible malignancy must be performed, when indicated.
19. Who Needs Special Evaluation
Without being a formal, absolute list of contraindications, individualised evaluation is especially needed in patients with:
Suspected or known prostate cancer that changes the treatment plan
Active urinary tract infection
Significant coagulation disorders
Unusual anatomical variants
Severe neurogenic bladder disorders
Very high anaesthetic risk
Prior urological procedures that may affect the technique
20. Anticoagulants / Antiplatelets
Individualised planning is required for patients on anticoagulant or antiplatelet therapy. Patients should not stop these medications on their own — the decision is made jointly by the urologist, cardiologist, and anaesthesiologist, where needed.
21. Outcomes & Durability Over Time
In the WATER trial, improvements in IPSS and Qmax were maintained at 5 years of follow-up, both after Aquablation and after TURP. Retreatment at 5 years was 5.1% after Aquablation and 1.5% after TURP in the same study. In the WATER II trial (80–150 mL), the need for surgical retreatment at 5 years was approximately 3%.
Long-term data for Aquablation continue to accumulate, but the follow-up history remains shorter than for longer-established techniques such as TURP.
22. Equipment & Surgical Team
Aquablation is performed with the AquaBeam system (PROCEPT BioRobotics) — mentioned here strictly for technical/informational purposes, not as commercial promotion. Dr. Marinos Vasilas collaborates with specialised surgical centres, including Lefkos Stavros – The Athens Clinic in Athens and the General Clinic of Rhodes (Euromedica), ensuring access to modern infrastructure and equipment.
Patient Journey, Step by Step
23. Frequently Asked Questions (FAQ)
What is Aquablation for the prostate?
Aquablation is an endoscopic treatment for benign prostatic hyperplasia in which obstructing prostate tissue is removed with a high-velocity waterjet, guided by real-time ultrasound imaging and a robotically controlled delivery system, without any external incision.
Is Aquablation really a robotic procedure?
A robotically guided system is used to execute the planned waterjet treatment, but the urologist plans and supervises the entire procedure in real time. It is not the same technology as da Vinci robotic surgery.
Does it use a laser?
No. Tissue removal is performed with a saline waterjet, not a laser. A laser may occasionally be used only for haemostasis at the end of the procedure, if needed.
What prostate size can be treated?
The EAU guideline’s strong recommendation applies to glands of 30–80 mL. For 80–150 mL glands there is feasibility data (the WATER II trial), but the guidelines state that further randomised trials are needed before an equally strong recommendation can be made.
Can it treat a very large prostate?
In selected patients with an 80–150 mL gland, the WATER II trial showed significant symptom improvement, but also a higher rate of bleeding-related events compared with smaller glands. Suitability is always individualised.
Does it affect ejaculation?
In the WATER trial, the anejaculation rate among sexually active men was lower after Aquablation than after TURP (10% vs 36%). This means a higher chance of preserving ejaculation compared with some traditional resection procedures — not a guarantee for every patient.
Does it affect erectile function?
Available data do not show a significant deterioration of erectile function in most patients, but there is no absolute guarantee — erectile function also depends on many other factors.
How long does the procedure take?
In the WATER trial, the waterjet ablation phase itself was significantly shorter than the equivalent resection step in TURP (about 4 vs 27 minutes), but total operating time was similar between the two techniques (about 33 vs 36 minutes), since it also includes access, mapping, and haemostasis.
How many days is a catheter needed?
A temporary urinary catheter is typically used, with early removal within the first few days achievable in many cases. The exact duration depends on prostate size, haemostasis, and the surgical centre’s protocol.
When can I return to normal activities?
Many patients notice gradual improvement over a few weeks, with a gradual return to normal activity following the surgeon’s guidance — there is no single timeline that applies to everyone.
Aquablation or HoLEP?
Both are effective techniques. HoLEP has more experience in very large glands and, in some comparisons, is associated with a greater improvement in Qmax, but also a higher risk of incontinence compared with Aquablation. The choice depends on prostate size and anatomy, patient priorities, and the surgical centre’s experience.
Might I need a repeat procedure in the future?
Yes, as with all surgical BPH treatments. In a 5-year follow-up study, retreatment after Aquablation was 5.1%, compared with 1.5% after TURP in the same study — long-term data for Aquablation continue to accumulate.
Related Topics
Rez\u016bm, HoLEP, TURiS, and laparoscopic adenomectomy are discussed for comparison purposes throughout this article; dedicated English-language pages for these procedures are not yet available.
Considering Treatment for BPH?
Choosing the right procedure for benign prostatic hyperplasia depends on gland size and anatomy, symptom severity, and the patient\u2019s priorities regarding recovery and sexual function. Book an appointment at our practice in Rhodes for a complete evaluation and comparison of Aquablation, HoLEP, and TURP.
References & Sources
- EAU Guidelines on Management of Non-neurogenic Male LUTS 2026 (Section 5.3.4.a – Aquablation) — uroweb.org
- Gilling P, et al. WATER: A Double-Blind, Randomized, Controlled Trial of Aquablation vs TURP for BPH — J Urol 2018;199:1252–1261, and five-year follow-up, BJU Int 2022.
- Desai M, et al. WATER II: Aquablation Therapy for Moderate-to-Severe LUTS in Patients with Large Prostates (80–150 mL) — J Urol 2019;201:1191–1197.
Medical Review
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas applies modern techniques for benign prostatic hyperplasia (HoLEP, TURiS, Rez\u016bm, Aquablation), with individualised selection based on gland size and patient needs, following EAU guidelines.
Full profileThe content on this page is for informational purposes only and does not replace an individualised urological evaluation. Not every patient is a candidate for Aquablation — the choice of method depends on anatomy, prostate size, comorbidities, and patient priorities.
