Aquablation for Benign Prostatic Hyperplasia (BPH)

Efficacy and Outcomes

The American Urological Association recommends Aquablation for BPH with a Conditional Recommendation and Evidence Level Grade C, citing its effectiveness in providing sustained improvements in International Prostate Symptom Score (IPSS) comparable to TURP through 12 months (RR 0.9 [95%CI 0.7 to 1.1]) 1
Aquablation demonstrates durable outcomes with 50% improvement in IPSS from baseline at 36 months, and shows significant improvement in quality of life scores (49% improvement from baseline at 3 years) 1
It produces similar maximum flow rate (Qmax) improvements compared to TURP at 12 months (10.3 vs. 10.6 mL/s), and maintains >50% improvement in Qmax from 3 to 24 months and 39% improvement at 36 months 1

Aquablation results in fewer Clavien-Dindo grade 2 complications compared to TURP at 3 months (26% vs. 42%, p=0.015), and shows similar rates of bladder spasms, bleeding, dysuria, pain, and urethral damage as TURP 1
It has comparable blood transfusion and reoperation rates to TURP (very low quality evidence), and demonstrates significantly lower rates of retrograde ejaculation compared to TURP (6% vs. 23%, p=0.002) 1
Aquablation may better preserve sexual function with fewer patients reporting worsening sexual function compared to TURP (33% vs. 56%, p=0.03) 1

The American Urological Association notes that long-term data beyond 3 years is currently limited, and evidence quality is moderate for symptom improvement but low to very low for other outcomes 1
Retreatment rates and long-term efficacy need further evaluation with larger studies, according to the American Urological Association 1

Aquablation provides noninferior functional outcomes compared to TURP in patients with LUTS and prostate volumes between 30-80 ml during mid-term follow-up 2, 3

Aquablation demonstrates fewer complications than TURP (26% vs 42%) 2, 3
Significant hemoglobin drop (2.06 g/dl) has been reported 2
Ejaculatory dysfunction rates are significantly lower with Aquablation compared to TURP (10% vs 36%) 2, 3

The European Association of Urology does not provide a specific recommendation strength for Aquablation in their 2023 guidelines 2, 3
There are still some concerns about the best methods for achieving post-treatment hemostasis 2, 3

Aquablation represents a viable alternative to TURP for BPH treatment, particularly for patients concerned about sexual function preservation 2, 3
The balance of efficacy (similar to TURP) with fewer complications makes it an attractive option for appropriate candidates 2, 3

The American Urological Association recommends surgery, including Aquablation, for patients with refractory urinary retention who have failed at least one attempt at catheter removal, with Aquablation being a conditionally recommended surgical option for BPH treatment 4
For patients with urinary retention specifically, the AUA guideline states that surgery remains the treatment of choice for refractory retention, assuming the patient is an acceptable surgical risk 4

Confirm diagnosis of BPH with total urinary retention 4
Attempt at least one catheter removal trial (possibly with alpha-blocker therapy) 4
If retention is refractory, evaluate surgical candidacy 4