What Are the Downsides of Aquablation?

Aquablation uses a high-pressure waterjet guided by real-time ultrasound to remove prostate tissue blocking urine flow, and while it has earned attention for preserving sexual function better than older surgeries, it carries real downsides that deserve honest discussion. The most prominent is postoperative bleeding, which has been the procedure’s Achilles’ heel since its early clinical use. But bleeding is not the only concern: higher costs, limited tissue for pathology, a surgeon learning curve, and specific recovery challenges all factor into the decision. The procedure is genuinely promising, yet no surgical option for an enlarged prostate is without trade-offs.

Bleeding Remains the Primary Risk

The single most discussed complication after Aquablation is postoperative hemorrhage. Because the waterjet ablates tissue without simultaneously cauterizing blood vessels the way electrical or laser tools do, bleeding control depends heavily on what the surgeon does after the cutting is finished. In the procedure’s early years, when catheter traction alone was the main method for tamping down bleeding, the hemorrhage rate requiring blood transfusion approached roughly 8% in some series, particularly in larger prostates.¹ A study of the WATER II trial, which specifically enrolled men with prostates between 80 and 150 mL, recorded bleeding complications in about 10% of patients before discharge, with nearly 6% needing a transfusion.²

The technique for managing bleeding has evolved. Surgeons increasingly perform selective cautery at the bladder neck after the waterjet finishes its work, and this has driven transfusion rates down. Across 801 patients treated between 2014 and early 2019, the overall transfusion rate was about 4%, but when surgeons used standard catheter traction combined with cautery only as needed, rates stayed between roughly 1.4% and 2.5% regardless of prostate size.³ A more recent real-world registry spanning six years reported that the combined rate of transfusion or return to the operating room for bleeding control dropped to just 0.2%.⁴

So the bleeding story has improved dramatically, but it has not disappeared. Prostate size is the strongest predictor of hemorrhage risk: the larger the gland, the more tissue the jet removes, and the more raw surface area is left behind. If you have a very large prostate and your surgeon is relatively new to the procedure, this risk is worth discussing explicitly before surgery.

Hospital Readmission and Catheter Reinsertion

A comparative analysis looking at 30- and 90-day outcomes found that patients who underwent Aquablation were more likely to be readmitted to the hospital and to need their urinary catheter reinserted compared to most other surgical options for an enlarged prostate.⁵ That finding comes with an important caveat: when the researchers excluded patients treated in the earliest adoption year (2023 in that dataset), the readmission difference went away. This suggests early institutional learning, rather than something inherent to Aquablation, may have been driving those extra readmissions. Still, for patients weighing their options, the possibility of a return hospital visit in the first few months is worth factoring in, especially at centers that are just starting to offer the procedure.

Catheter reinsertion typically happens because of urinary retention after the initial catheter is removed. The prostate cavity is swollen and healing, and some men temporarily cannot void on their own. This is not unique to Aquablation, but because the waterjet creates a somewhat different wound profile than electrosurgical or laser tools, the pattern of swelling and clot formation can be distinct. One study comparing Aquablation directly to laser enucleation found that gross blood in the urine and urinary retention were more common after Aquablation, though the difference did not reach statistical significance.⁶

Ejaculatory Dysfunction Still Happens

One of Aquablation’s biggest selling points is that it preserves ejaculatory function better than the traditional gold standard, transurethral resection of the prostate (TURP). In a randomized trial, complete loss of ejaculation occurred in 10% of sexually active men after Aquablation compared to 36% after TURP at two years.⁷ That is a meaningful difference. But “better than TURP” is not the same as “no risk.” One in ten men still lost ejaculation entirely, and when post-Aquablation cautery was performed, that figure rose to about 16%.

A French registry of patients with smaller-to-medium-sized prostates found new ejaculatory dysfunction in roughly 27% of patients at six months.⁸ That registry also reported no new cases of erectile dysfunction or incontinence, which is reassuring for those specific concerns. Erectile function appears well preserved across the literature: the randomized trial against TURP recorded zero cases of new erectile dysfunction in either arm, and a systematic review of robotic waterjet ablation found no meaningful changes on standardized erectile function questionnaires.⁹

The bottom line on sexual function is nuanced. If your primary worry is erectile dysfunction, Aquablation looks very safe. If preserving ejaculation matters to you, Aquablation is genuinely better than TURP, but it is not a guarantee. Roughly one in four men may notice some change in ejaculatory function, and a smaller subset will lose it altogether.

How It Stacks Up Against Laser Enucleation

Holmium laser enucleation (HoLEP) is increasingly considered the modern benchmark for prostate surgery, especially for large glands. Two direct comparisons between Aquablation and HoLEP reveal a mixed picture that matters if you are trying to choose between them.

In a prospective non-randomized study, HoLEP was associated with shorter operating times and better prostate volume reduction at all follow-up points. Aquablation showed an early advantage in ejaculatory and continence function at three months, but beyond that window, the two procedures performed similarly on erectile function, ejaculatory function, continence, and symptom relief. The more concerning finding was that severe complications (Clavien-Dindo grade 3b or higher, meaning events requiring intervention under general anesthesia) occurred in six Aquablation patients compared to just one HoLEP patient.¹⁰

A propensity-score matched analysis told a similar story with some different accents: both procedures improved symptoms equally, but HoLEP produced greater gains in urinary flow rate. Aquablation did significantly better at preserving ejaculation. Temporary incontinence was more frequent after HoLEP, while blood in the urine and urinary retention were more common after Aquablation, though neither complication difference was statistically significant.⁶

A newer trial comparing Aquablation to transurethral laser enucleation found that persistent stress urinary incontinence was absent after Aquablation but occurred in about 9% of patients after laser enucleation.¹¹ So Aquablation’s continence profile looks favorable, but its bleeding and severe complication profile looks slightly worse. For a man who values ejaculation preservation and is concerned about long-term incontinence, Aquablation has a genuine argument. For someone who prioritizes the lowest possible risk of ending up back in an operating room, HoLEP may be the safer bet.

Destroyed Tissue Cannot Be Properly Examined

This is a downside that rarely makes the marketing materials. When TURP or HoLEP removes prostate tissue, pathologists can examine the specimens under a microscope and occasionally catch incidental prostate cancer that was not detected on prior biopsies. Aquablation’s high-pressure waterjet, by contrast, pulverizes tissue into fragments so severely damaged that meaningful pathologic assessment is often impossible.¹²

How much does this matter in practice? Incidental prostate cancer found during BPH surgery is not especially common, and most men undergoing these procedures have already had some form of cancer screening. But it is not zero, and for certain patients who have borderline PSA levels or suspicious findings that did not quite warrant a biopsy, the inability to examine the removed tissue is a genuine diagnostic gap. If your urologist has any lingering concern about prostate cancer, this limitation should be part of the conversation about whether Aquablation is the right choice for you.

The Procedure Costs More

Aquablation requires a proprietary robotic system and single-use disposable components, and that drives costs up compared to traditional surgery. A Swiss hospital-level analysis found that the average total cost per patient for Aquablation was roughly €11,000 compared to about €7,400 for TURP, a statistically significant difference of approximately €3,500. The gap was almost entirely explained by higher procedural costs, particularly the price of the disposable supplies needed for the waterjet system.¹³

Whether this cost difference is justified depends on what you value. If Aquablation leads to fewer retreatments and preserved sexual function over the long term, the upfront premium could pay for itself. But the honest answer is that long-term cost-effectiveness data is still thin. A UK National Health Service analysis noted that existing studies have focused on short-term hospital costs and have not accounted for capital equipment expenses, long-term clinical outcomes, or quality-adjusted life years.¹⁴ For patients paying out of pocket or navigating insurance coverage, the higher price tag is a practical barrier that cannot be hand-waved away with theoretical downstream savings.

Access is another consideration. The robotic system is expensive for hospitals to acquire, so Aquablation is concentrated in larger urban medical centers. If you do not live near one, you may face travel and logistical costs on top of the procedure itself.

The Learning Curve Matters

Aquablation is partially automated: the surgeon plans the resection zone on ultrasound, and the robot executes the waterjet cut. This gives the impression that the procedure is less operator-dependent than traditional surgery. That impression is only partly true. While the cutting itself is standardized, the planning of the resection zone, the management of hemostasis afterward, and the judgment calls around patient selection all depend on surgeon experience. Complication rates, particularly bleeding and the need for reoperation, tend to be higher during a surgeon’s early cases and stabilize as familiarity with the technique grows, especially at high-volume centers.¹⁵

This is consistent with the readmission data discussed earlier, where early adoption years showed higher readmission rates that faded as experience accumulated. If you are considering Aquablation, asking your surgeon how many procedures they have performed and what their center’s complication rates look like is entirely reasonable. A procedure that is partly robotic still depends on a human making the key decisions.

Irritative Symptoms During Recovery

Men recovering from Aquablation commonly experience urgency, frequency, and burning during urination in the first weeks to months. This is true of most prostate surgeries, but the nature of the waterjet wound means the healing cavity can produce significant irritative symptoms. A randomized trial found that giving men a short course of alpha-blocker medication for one month after Aquablation led to better early outcomes, including less pain and fewer irritative symptoms at three months. Even at twelve months, the treated group still showed a meaningful edge in irritative symptom scores.¹⁶ This suggests the early recovery period is uncomfortable enough that proactive management makes a real difference, and patients should expect to budget several weeks of significant urinary bother before things settle down.

What the Long-Term Data Actually Shows

Five-year follow-up from the original WATER and WATER II trials shows that Aquablation’s symptom improvements hold up well over time. Symptom scores dropped from severe at baseline to mild at five years, and urinary flow rates roughly doubled and stayed there. Importantly, the vast majority of patients in both trials remained free of BPH medication (94% to 99%) and free of surgical retreatment (95% to 97%) at the five-year mark.¹⁷ The retreatment rate works out to roughly 1% per year, and compared to TURP, the risk of needing additional BPH therapy was about half.¹⁸

Those numbers look good, but five years is still a relatively short track record for a prostate procedure. TURP and HoLEP have decades of follow-up data behind them. Men in their fifties or early sixties considering Aquablation are making a bet that the durability will hold for fifteen or twenty years, and that data simply does not exist yet. The initial trajectory is encouraging, but it is fair to call this a limitation of a newer technology.

When Aquablation Is Not the Right Fit

Aquablation works across a wide range of prostate sizes, and the WATER trials demonstrated consistent results in glands from 30 mL all the way up to 150 mL.¹⁹ That said, the procedure is performed under general anesthesia and requires a hospital stay, which makes it a poor match for men who need or prefer an office-based procedure with minimal sedation. It also requires spinal or general anesthesia, so men with significant anesthesia risks may be better served by less invasive options like prostatic urethral lift or water vapor therapy, which can be done under local anesthesia.

Men with suspected or confirmed prostate cancer are generally not good candidates, both because the procedure is designed for benign disease and because, as noted above, the tissue destruction makes pathologic evaluation unreliable. And for men whose primary concern is getting the absolute maximum tissue removal in one session with the longest possible durability track record, HoLEP still has the edge in terms of the volume of tissue it can remove and the depth of follow-up data supporting it.