Aquablation is a minimally invasive surgical treatment for an enlarged prostate (benign prostatic hyperplasia, or BPH) that uses a high-pressure waterjet, guided by a robot and real-time ultrasound imaging, to remove excess prostate tissue blocking urine flow. It was approved by the FDA as a heat-free alternative to traditional prostate surgeries, which rely on electrical current or laser energy to cut or vaporize tissue. Because it avoids heat entirely, it eliminates the risk of thermal injury to surrounding structures, a meaningful advantage for preserving sexual function.
How the Procedure Works
The surgeon begins by inserting a thin scope through the urethra into the bladder. Once positioned, a bi-plane transrectal ultrasound probe provides live imaging of the prostate in two planes, giving the surgeon a detailed cross-sectional view. Using this imaging, the surgeon manually outlines the boundaries of tissue to be removed, essentially drawing a resection map on a console screen. Prostate dimensions are entered, and the surgeon adjusts parameters like water pressure, flow rate, and the angle of each pass.
Once the plan is set, the robot executes the waterjet passes automatically, following the mapped contours with a level of precision that would be difficult to achieve by hand. The surgeon supervises the entire process in real time and can pause, modify, or abort at any point. The waterjet selectively removes soft prostate tissue while preserving harder structures like blood vessels and the surrounding capsule. This conformal approach means the treatment is tailored to each patient’s unique anatomy rather than following a one-size-fits-all cutting path.
Who Is a Candidate
Aquablation has been studied and shown effective across a wide range of prostate sizes. Clinical trials have enrolled men with prostates from 30 to 150 cc (roughly equivalent to cubic centimeters or grams), which covers small, medium, and large glands. This is a notable advantage. Many competing procedures work best within a narrower size window, and men with very large prostates (above 80 cc) historically had limited options. Open surgery carries more risk, traditional resection of large glands can take a long time with increased bleeding, and laser enucleation, while effective, requires a specialized skill set that relatively few urologists have.
Aquablation is designed for men with moderate to severe urinary symptoms from BPH, the kind of difficulty starting urination, weak stream, frequent nighttime trips to the bathroom, and incomplete emptying that significantly affects quality of life.
Symptom Relief and Effectiveness
The primary way doctors measure BPH treatment success is through the International Prostate Symptom Score (IPSS), a questionnaire that quantifies how much urinary trouble a patient experiences on a scale of 0 to 35. In the most recent clinical trial (WATER III), men treated with aquablation saw their scores drop by about 13 points at three months, nearly identical to the improvement seen with laser enucleation, which is considered a gold standard for large prostates. That level of improvement typically represents a shift from severe symptoms to mild ones.
Long-term durability looks solid as well. At five years, surgical retreatment rates for aquablation range from 4.4% to 6%, meaning roughly 94 to 96 out of every 100 men did not need another procedure. Only about 4.4% of patients went back on BPH medication within five years.
Sexual Function Preservation
This is where aquablation stands out most clearly. Because the waterjet doesn’t generate heat, it avoids the collateral damage to nerves and tissues that traditional procedures can cause. A systematic review of the evidence found that 72% to 99.6% of men retained normal (antegrade) ejaculation after aquablation. Erectile function remained stable across all reviewed studies.
For comparison, a randomized trial pitting aquablation against traditional transurethral resection (TURP) found significantly lower rates of ejaculatory problems in the aquablation group, and that advantage held up through five years of follow-up. The WATER III trial also showed superior ejaculation preservation compared to laser enucleation. For men who consider sexual function a priority, these outcomes are a meaningful differentiator.
Risks and Complications
The most significant risk with aquablation is bleeding. Across more than 800 procedures analyzed in one large study, the overall blood transfusion rate was 3.9%. Most transfusions happened before hospital discharge, and none occurred beyond 30 days after surgery.
Prostate size is the biggest factor in bleeding risk. For average-sized glands with standard post-procedure techniques, the transfusion rate drops to about 1.9% regardless of prostate size. Larger prostates (100 to 150 cc) carry higher rates, reaching roughly 6.7% before discharge in one trial. Surgeons manage this by selectively cauterizing blood vessels at the bladder neck when needed, a targeted use of heat applied only for bleeding control rather than tissue removal.
Temporary urinary side effects like urgency, frequency, or mild incontinence can occur during healing, consistent with any procedure that removes prostate tissue from around the urethra. The WATER III trial noted that aquablation avoided stress urinary incontinence more effectively than laser enucleation in the short term.
What Recovery Looks Like
Aquablation is performed under general anesthesia and typically requires a short hospital stay. After the procedure, a catheter is placed to drain urine while the treatment area heals. You can expect some blood in the urine during the initial recovery period, which gradually clears. Most men notice meaningful improvement in urinary symptoms within the first few weeks, though full healing and final results develop over the following months.
Because the robotic system handles the tissue removal in a standardized way, operative times tend to be shorter and more predictable than with manual surgical techniques, particularly for larger prostates where traditional procedures can stretch well past an hour. The consistency of the robotic execution also means outcomes are less dependent on an individual surgeon’s hand skills, though surgical planning and judgment still play a critical role in the result.
How It Compares to Other BPH Treatments
Aquablation occupies a specific niche: it offers symptom relief comparable to the most effective surgical options (TURP, laser enucleation) while preserving sexual function at rates closer to less invasive therapies. Traditional TURP remains the most widely performed BPH surgery, but it carries higher rates of ejaculatory dysfunction. Laser enucleation is highly effective for large prostates but requires significant surgical expertise and has similar sexual side effect trade-offs.
Less invasive options like the UroLift system or steam-based treatments preserve sexual function well but generally produce more modest symptom improvement and have higher retreatment rates over time. Aquablation bridges that gap, delivering durable, substantial symptom relief without the sexual function trade-off that has historically come with more aggressive surgery.