Aquablation Therapy: Robotic Water Jet Ablation for BPH – Complete Guide

What is Aquablation?

Aquablation is a minimally invasive, robotic‑assisted treatment for benign prostatic hyperplasia (BPH) that uses a high‑velocity water jet to precisely remove prostate tissue. It is the first and only heat‑free robotic water jet ablation technology for BPH.

The Aquablation system was FDA‑approved in 2017 and has been performed on thousands of men worldwide. It is particularly effective for large prostates (80-150 mL) where other MISTs may be less effective.

How does Aquablation work?

Aquablation uses a robotic‑controlled, heat‑free water jet to remove prostate tissue under real‑time ultrasound guidance.

The technology:

• A robotic handpiece is inserted through the urethra into the prostate
• Real‑time ultrasound imaging (not just cystoscopy) allows the surgeon to visualise the entire prostate, including the ejaculatory ducts
• The surgeon uses a joystick to map the treatment area, avoiding the ejaculatory ducts and bladder neck
• A high‑velocity saline jet (water) is then delivered robotically to remove the mapped tissue
• No heat is used – eliminating thermal damage to surrounding structures
• Tissue is evacuated (suctioned out) during the procedure

Key advantages:

• Real‑time imaging (ultrasound + cystoscopy)
• Heat‑free – no thermal injury to nerves or tissue
• Robotic precision – consistent, reproducible results
• Preserves ejaculatory function better than TURP
• Works for large prostates (30-150 mL, ideal for 80-150 mL)

Who is a good candidate for Aquablation?

Ideal candidates for Aquablation meet the following criteria:

• Prostate size: 30-150 mL (excellent for 80-150 mL, where other MISTs are less effective)
• Symptoms: Moderate to severe BPH symptoms (IPSS ≥12)
• Medication failure: Poor response or intolerance to BPH medications
• Large median lobe (Aquablation handles median lobes very well)
• Accepts risk of retrograde ejaculation (40-60% rate – lower than TURP's 70-80%)

Who is NOT a good candidate?

• Very small prostates (<30 mL) – other MISTs (Rezum, UroLift) are better
• Active urinary tract infection
• Bladder stones (can be treated concurrently)
• Urethral stricture (narrowing) that prevents scope passage
• Known prostate cancer (requires different treatment)

The Aquablation procedure – what to expect

Before the procedure:

• Stop blood thinners (if possible – discuss with your doctor)
• Antibiotics may be prescribed to prevent infection
• No special bowel preparation required

Day of procedure:

• Performed in a hospital operating room
• Anaesthesia: General anaesthesia (you are fully asleep)
• Duration: 30-60 minutes
• Hospital stay: Usually overnight (1-2 days)

Step-by-step:

1. The Aquablation handpiece is inserted through the urethra
2. Ultrasound imaging creates a real‑time 3D map of the prostate
3. The surgeon uses a joystick to outline the treatment area (avoiding ejaculatory ducts and bladder neck)
4. The robotic water jet is activated, removing the mapped tissue
5. Tissue is evacuated through the handpiece
6. A urinary catheter is placed (required for 1-2 days)

Recovery and downtime

Immediate post-procedure (first week):

• Catheter: Required for 1-2 days (all patients)
• Hospital stay: 1-2 days overnight
• Blood in urine (hematuria): Common – lasts 1-2 weeks
• Burning with urination (dysuria): Common – lasts 1-2 weeks
• Increased frequency/urgency: Temporary, improves over 2-4 weeks

Return to activities:

• Desk work: 1-2 weeks
• Physical labour: 3-4 weeks
• Exercise (light): 2 weeks
• Sexual activity: 3-4 weeks (after discomfort resolves)

Symptom improvement timeline:

• Week 1-2: Temporary worsening due to swelling (normal)
• Week 4: Initial symptom improvement begins
• Month 3: Significant improvement
• Month 6: Maximum benefit achieved

Effectiveness – symptom improvement and durability

Clinical studies demonstrate excellent outcomes with Aquablation, especially for large prostates:

5-year clinical trial results (WATER study):

• IPSS reduction: 60-70% (e.g., 22 → 7-8) – comparable to TURP
• Peak flow rate (Qmax) increase: 100-150% (e.g., 9 → 18-22 mL/s) – superior to TURP in some studies
• Prostate size reduction: 50-70%
• Quality of life improvement: Excellent (QoL score improved by 70%)

Durability:

• 5-year data: Sustained improvement with low re-treatment rates (5-10%)
• Results comparable to TURP (the gold standard)

Patient satisfaction:

• 85-90% of men report being satisfied or very satisfied at 5 years
• Equivalent to TURP satisfaction rates

Side effects – retrograde ejaculation, hematuria, dysuria

Aquablation has a favourable side effect profile compared to TURP:

Common side effects (occur in >10%):

• Hematuria (blood in urine): 80-90% – mild, resolves in 1-2 weeks
• Dysuria (painful urination): 60-70% – mild, lasts 1-2 weeks
• Urinary frequency/urgency: 50-60% – temporary
• Retrograde ejaculation: 40-60% (lower than TURP's 70-80%)

Less common side effects (2-10%):

• Urinary tract infection: 5-10%
• Urinary retention (temporary): 5-10%
• Urethral stricture: 2-5%

Rare side effects (<2%):

• Erectile dysfunction: <3% (significantly lower than TURP's 5-10%)
• Urinary incontinence: <1%
• Blood transfusion: <1%

Aquablation vs. TURP vs. HoLEP vs. Rezum

Feature	Aquablation	TURP	HoLEP	Rezum
Anaesthesia	General	General/spinal	General	Local + sedation
Hospital stay	1-2 days	1-2 days	1-2 days	None
Catheter required	1-2 days (100%)	1-2 days (100%)	1-2 days (100%)	1-3 days (10-15%)
Return to work	1-2 weeks	2-4 weeks	2-4 weeks	1-3 days
Prostate size range	30-150 mL	30-100 mL	30-200+ mL	30-80 mL
IPSS reduction	60-70%	60-70%	70-80%	50-60%
Retrograde ejaculation	40-60%	70-80%	70-80%	20-30%
Erectile dysfunction risk	<3%	5-10%	5-10%	<2%
5-year durability	Excellent	Excellent	Excellent	Good

Cost and insurance coverage

• Medicare: Covers Aquablation for eligible patients (must meet criteria)
• Private insurance: Most major insurers cover Aquablation (coverage varies – check with your plan)
• Out-of-pocket cost: $5,000-$10,000 depending on insurance, deductibles, hospital stay, and anaesthesia fees
• Compared to TURP: Aquablation is generally more expensive than TURP due to the robotic technology

Interactive FAQ – Aquablation therapy

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Disclaimer: This information is for educational purposes. Aquablation is a medical procedure with risks and benefits. Discuss with a urologist at Vivekananda Hospital to determine if Aquablation is right for you.