Since February 2025, several significant studies have redefined the clinical boundaries of Aquablation. March 2025 proved to be a particularly fruitful month for studies directly comparing Aquablation and HoLEP. The 3-month results of the WATER III trial, presented in March at the European Association of Urology Congress, compared Aquablation with laser enucleation (Holmium Laser Enucleation of the Prostate (HoLEP)/Thulium Laser Enucleation of the Prostate(ThuLEP) in 202 men with large prostates (volume range: 80–180 mL). At three months, both groups achieved equivalent symptom relief. However, the functional advantages of Aquablation were striking: ejaculatory dysfunction in only 15 % of sexually active men versus 77 % with HoLEP, and lower transient incontinence rates (9 % vs 20 %). Although HoLEP produced greater prostate-volume reduction, as one might expect, and Qmax improvement, the overall message was clear—Aquablation matches the gold standard for efficacy while preserving the elements of quality of life that matter most to patients.
Additionally, a comparative trial published in March has confirmed this trend. Quintas et al. reported no difference in symptom or flow outcomes between Aquablation and HoLEP, yet a 13-fold lower rate of ejaculatory dysfunction (6.6% vs. 89%).1
In September 2025, Oh and Kim used propensity-score matching to show equivalent safety and symptom improvements between Aquablation and HoLEP, again demonstrating Aquablation’s clear advantage in ejaculation preservation.
Even in very large prostates, Gangwish et al. demonstrated that Aquablation delivered a similar quality-of-life improvement to simple prostatectomy, while achieving markedly fewer transfusions, shorter hospital stays, and two hours less operating time.2
Meanwhile, the delivery model for Aquablation has evolved just as rapidly. Zorn et al. demonstrated the feasibility of same-day discharge,3 and the first U.S. pilot by Marhamati et al. confirmed that 101 men were safely treated in ambulatory centres with no overnight capacity—discharged after a mean recovery of 1.5 hours, IPSS improvement from 22 to 9, and only 1 % major complications.4 Economic analysis revealed savings of approximately $1,800 per case compared to hospital-based procedures, highlighting that Aquablation is not only clinically sound but also financially sustainable.
Adding a global dimension, Bitar Siqueira et al. pooled 528 patients from five international studies—WATER, WATER II, OPEN WATER, FRANÇAIS WATER, and JAPAN PMS—confirming durable, reproducible benefits across continents and healthcare systems.5 At 12 months, mean IPSS dropped from 21.5 to 6.6, Qmax more than doubled, and post-void residual volume halved, with consistent safety across prostate sizes up to 242 mL.
Together, these data reveal a clear pattern: Aquablation has matured from a promising alternative to a platform technology that is reproducible, durable, and increasingly ambulatory. It offers the precision of robotics, the functional preservation patients value, and the efficiency modern health systems demand.
In short, what began as making waves in prostate surgery is fast becoming a tsunami of evidence and adoption. The following chapters—long-term durability, cost-effectiveness, and integration into outpatient networks—are already taking shape.
Written by: Lodewikus P. Vermeulen, MBChB, FC Urol (SA), MMed Urol, FRACS, FACS, MBA, Urology Department, Tauranga Hospital, Auckland University, Tauranga, Bay of Plenty, New Zealand
References:
- Quintas JJ, García Rojo E, García Gómez B, et al. Aquablation vs. holmium laser enucleation of the prostate for benign prostatic hyperplasia: a 150-patients prospective comparative multicenter study. Minerva Urol Nephrol. 2025 Feb;77(1):111-119. doi:10.23736/S2724-6051.24.05871-3. PMID:39932697.
- Oh KT, Kim JH. Aquablation versus HoLEP: Propensity score matching analysis of functional outcomes and ejaculation preservation. Investig Clin Urol. 2025 Sep;66(5):431-438. doi:10.4111/icu.20250055. PMID:40897661.
- Zorn KC, Chakraborty A, Chughtai B, Mehan R, Elterman D, Nguyen DD, Bouhadana D, Glaser AP, Marhamati S, Barber N, Helfand BT. Safety and Efficacy of Same Day Discharge for Men Undergoing Contemporary Robotic-assisted Aquablation Prostate Surgery in an Ambulatory Surgery Center Setting-First Global Experience. Urology. 2025 Jan;195:132-138. doi:10.1016/j.urology.2024.08.006. PMID:39159759.
- Marhamati S, et al. First-in-US Pilot Study of Aquablation in Ambulatory Surgery Centers: Clinical Outcomes and Economic Feasibility. Urology. 2025 Sep 25:S0090-4295(25)00909-4. Online ahead of print. doi:10.1016/j.urology.2025.09.032. PMID:41015303.
- Bitar Siqueira MH, Berjaoui MB, Bhojani N, et al. Outcomes of aquablation: pooled analysis from the WATER, WATER II, OPEN WATER, FRANCAIS WATER, and JAPAN PMS studies. World J Urol. 2025 Oct 28;43(1):635. doi:10.1007/s00345-025-06033-1. PMID:41148264.