Aqua Ablation (Aquablation)

At a glance

• What it is: Aquablation, sometimes searched as Aqua Ablation, is a robotic, image-guided waterjet procedure for selected men with lower urinary tract symptoms from benign prostatic hyperplasia (BPH). A high-velocity saline jet removes a surgeon-planned volume of obstructing prostate tissue.^1,2
• How it differs: Unlike TURP, GreenLight laser, Rezum and HoLEP, the tissue-removing step does not use heat. The treatment plan is drawn on real-time ultrasound, then a robotic handpiece delivers the waterjet through the urethra.^1,2
• Who it may suit: Selected men with bothersome BPH symptoms who are considering a procedural option, especially when prostate size or shape makes a simple office procedure less suitable and preservation of ejaculation is an important priority.^2,3,4
• What the evidence shows: In the WATER randomised trial for 30 to 80 mL prostates, Aquablation produced symptom and flow improvements comparable with TURP at 5 years, with lower procedure-related ejaculatory dysfunction in the published trial.³ Evidence for large prostates is growing but remains less mature than for long-established operations such as TURP and HoLEP.^4,5
• Where it fits: Aquablation sits between minimally invasive BPH options and more established tissue-removing operations. It is one option to discuss alongside medication, UroLift, Rezum, iTind, PAE, TURP, GreenLight laser, HoLEP and simple prostatectomy.

What is Aquablation?

Aquablation is the brand name for transurethral waterjet ablation using the AquaBeam robotic system. The surgeon inserts a handpiece through the urethra and uses transrectal ultrasound to map the prostate in real time. The treatment zone is planned on the imaging display, including areas to avoid near the external sphincter and ejaculatory structures.^1,2

Once the plan is confirmed, the robotic system delivers a high-speed saline waterjet to remove the planned obstructing tissue. The waterjet itself is heat-free. Bleeding control is usually managed afterwards with standard endoscopic measures such as focal cautery, catheter balloon pressure and bladder irrigation.^1,2

Because tissue is removed, Aquablation is closer to TURP or laser surgery than to purely implant-based options such as UroLift. It is still an operation, usually performed under general or spinal anaesthesia, and it usually involves a catheter afterwards.

How is Aquablation different from other BPH treatments?

The distinguishing feature is the combination of real-time ultrasound planning and robotic execution of a heat-free waterjet. The surgeon defines the area to treat, and the system follows that plan with controlled depth and angle. This can be useful in prostates where the obstructing tissue has an irregular shape or a median lobe.^1,2

Compared with TURP, Aquablation aims to provide similar symptom relief while reducing thermal injury and improving the chance of preserving ejaculation in selected men.³ Compared with HoLEP, Aquablation has a shorter published follow-up history and fewer direct head-to-head comparative data; HoLEP remains one of the most established options for large prostates.

Compared with PAE, Aquablation is a urological operation through the urinary channel and directly removes prostate tissue. PAE is an interventional radiology procedure through the arteries and works by reducing blood supply to the prostate.

What the evidence and guidelines say

NICE's medtech innovation briefing describes Aquablation as a transurethral waterjet ablation option for lower urinary tract symptoms caused by BPH when surgical intervention is being considered. NICE summarised evidence from 5 studies including 562 people, with one randomised comparison against TURP, and noted that further direct comparative evidence with other technologies is still needed.¹

In the WATER randomised trial, 181 men with 30 to 80 mL prostates were randomised to Aquablation or TURP. At 5 years, International Prostate Symptom Score (IPSS) improved by 15.1 points after Aquablation and 13.2 points after TURP. Procedure-related ejaculatory dysfunction was lower after Aquablation in the published trial (7% vs 25%).³

The WATER II study and later follow-up report Aquablation experience in larger prostates, generally 80 to 150 mL, but this evidence is mostly single-arm rather than randomised against HoLEP or simple prostatectomy.^4,5 This is why Aquablation should be discussed as one option, not as a universal replacement for established BPH operations.

Who may be suitable?

Aquablation may be considered when:

• Symptoms are bothersome enough to consider a procedure after lifestyle measures or medication.
• The prostate size and shape are within the treating centre's Aquablation pathway.
• The patient wants a tissue-removing procedure but places a high value on reducing the risk of ejaculatory dysfunction.
• A median lobe or larger gland makes very small minimally invasive procedures less suitable.

Aquablation may be less suitable when:

• The main problem is bladder dysfunction rather than prostate obstruction.
• There is suspected prostate cancer, bladder cancer, urethral stricture, bladder stone, or another diagnosis that needs separate assessment.
• The patient needs the most established long-term evidence for a very large gland, where HoLEP or simple prostatectomy may be preferred.
• The hospital or treating team does not have access to the Aquablation system or the required training pathway.

How Aquablation is performed

1. Assessment and planning. Symptoms, prostate size, urine flow, residual urine, PSA context and bladder factors are reviewed before choosing a procedure.
2. Anaesthesia. Aquablation is usually performed under general or spinal anaesthesia.^1,2
3. Ultrasound mapping. A transrectal ultrasound probe maps the prostate while the transurethral handpiece is positioned.
4. Surgeon-planned treatment zone. The surgeon draws the planned ablation area and defines structures to protect.
5. Robotic waterjet ablation. The system delivers the saline waterjet through the planned tissue volume.
6. Bleeding control and catheter. Endoscopic cautery, catheter balloon pressure and bladder irrigation may be used. A catheter is usually left in place for a period after the procedure.

What to expect after Aquablation

Most patients stay in hospital until urine colour, catheter drainage and comfort are satisfactory. Catheter duration varies by prostate size, bleeding risk and hospital protocol. Temporary burning, urgency, frequency and blood in the urine can occur during early healing.

Improvement in urinary flow may be noticed relatively early, but irritative symptoms can take weeks to settle. Follow-up usually checks symptom score, urine flow, residual urine and whether medication can be reduced or stopped.

Risks and limitations

Aquablation removes prostate tissue and carries many of the same broad risks as other endoscopic BPH operations. Important risks to discuss include:

• Bleeding, which can require bladder irrigation, return to theatre, transfusion or delayed readmission in some cases.
• Urinary retention or delayed catheter removal.
• Urinary infection, pain, burning, urgency or frequency during healing.
• Retrograde ejaculation or reduced ejaculate volume. The risk appears lower than TURP in the WATER trial, but it is not zero.³
• Erectile dysfunction, uncommon but possible after any prostate procedure.
• Urethral stricture or bladder neck contracture, which may need later treatment.
• Incomplete symptom relief or retreatment. Some men need ongoing medication or another BPH procedure later.
• Evidence maturity. Five-year randomised data are available for 30 to 80 mL prostates, but long-term data beyond this and direct comparisons with HoLEP remain more limited.^1,3,4,5

Aquablation at Urology NSW

Urology NSW can assess men with BPH symptoms and explain how Aquablation compares with other options. Whether it is appropriate depends on prostate size and shape, bladder function, symptom severity, medical history, treatment availability and the patient's priorities.

Some men are better served by medication, UroLift, Rezum, iTind or PAE. Others need a more established tissue-removing operation such as HoLEP, TURP, GreenLight laser or simple prostatectomy. The consultation is designed to match the procedure to the individual anatomy and goals, not to promote one technology for every patient.

Frequently asked questions

Is Aqua Ablation the same as Aquablation?

Yes. Patients often search for "Aqua Ablation", but the procedure name is usually written as Aquablation. It refers to robotic waterjet ablation of prostate tissue for selected men with BPH.

Is Aquablation heat-free?

The tissue-removing waterjet step is heat-free. Some heat may still be used afterwards for haemostasis, such as focal cautery around bleeding areas or the bladder neck.^1,2

Does Aquablation preserve ejaculation?

It may reduce the risk of ejaculatory dysfunction compared with TURP in selected men, but it does not guarantee preservation. The WATER trial reported lower procedure-related ejaculatory dysfunction after Aquablation than TURP, and this should be discussed in the context of the individual's anatomy and priorities.³

Is Aquablation better than HoLEP?

Not as a general statement. Aquablation and HoLEP have different strengths, availability and evidence histories. HoLEP has a long track record across a wide prostate-size range; Aquablation has randomised evidence against TURP and is designed around ultrasound planning and waterjet tissue removal. The better fit depends on the individual situation.