Aquablation (sold under the AquaBeam name) is a newer entrant in the BPH surgery landscape — a robot-guided procedure that uses a high-velocity water jet, under real-time ultrasound imaging, to remove obstructing prostate tissue without heat. What sets it apart from most of the newer minimally invasive BPH options isn't marketing — it's that Aquablation has been tested in actual randomized controlled trials against the two procedures urologists already trust, out to 5 years, by the same research group each time. That's a genuinely unusual evidence base for a device this new, and it's worth understanding what it does and doesn't show.
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How It's Different From Heat-Based Procedures
TURP, laser enucleation (HoLEP/ThuLEP), and Rezūm all rely on heat — electrocautery or laser energy — to cut or ablate obstructing prostate tissue. Aquablation uses a heat-free, high-pressure water jet, guided by a surgeon watching real-time ultrasound, to map out and remove tissue mechanically. The proposed clinical advantage is precision without thermal damage to surrounding structures — specifically the nerves and muscle involved in ejaculation, which heat-based resection can damage even when it successfully relieves urinary symptoms.
The Core Trial: Aquablation vs. TURP, Out to 5 Years
The WATER trial randomized 181 men with moderate-to-severe BPH symptoms to Aquablation or TURP in a double-blind design — patients and follow-up assessors didn't know which procedure they'd had. At 6 months, both groups had large symptom improvements, and Aquablation met its pre-specified non-inferiority bar for efficacy. On safety, Aquablation actually came out ahead: a 26% complication rate versus 42% for TURP, meeting superiority (not just non-inferiority) [1]. The finding that got the most attention: among sexually active men, anejaculation occurred in 10% of the Aquablation group versus 36% of the TURP group [1].
At the 5-year follow-up of that same trial, symptom improvement remained durable in both groups (IPSS improved 15.1 points with Aquablation vs. 13.2 with TURP), but men with larger prostates (50mL or more) saw a meaningfully bigger benefit from Aquablation — a 3.5-point greater IPSS reduction sustained across every follow-up visit. The need for a second BPH procedure by 5 years was 51% lower in the Aquablation group [2].
- •The ejaculation-preservation finding held up over time, not just in the first few months — this matters because some early post-surgical improvements fade
- •The larger-prostate subgroup benefit is a real, specific finding, not a general claim that Aquablation beats TURP for every patient regardless of gland size
- •Retreatment rate (needing a second procedure for recurring symptoms) is a meaningful long-term outcome that short trials can't capture — this is genuinely 5-year data, not an extrapolation
Very Large Prostates: The Comparison That Matters Most
TURP and standard minimally invasive options are typically not recommended for very large prostates (80mL+) — that's traditionally been laser enucleation's territory. A 2026 trial (WATER III) directly compared Aquablation to laser enucleation in men with 80-180mL prostates and found similar symptom improvement at 3 months, with Aquablation showing a lower rate of retrograde ejaculation (14.8% vs. 77.1%) and zero cases of persistent stress urinary incontinence versus 9.3% with laser enucleation [3]. A separate 1-year cohort of 101 men with 80-150mL prostates treated with Aquablation alone found IPSS improved from 23.2 to 6.2, with 81% of sexually active men maintaining antegrade ejaculation [4]. For men with large glands specifically, this is where Aquablation's case looks strongest.
IPSS is the same validated score these trials used as their primary outcome — and it's exactly what you can track yourself before and after any BPH procedure to see your own real trend, rather than relying on how you feel in the moment. Log it in the ManCore dashboard.
The One Honest Caveat: Who Funded These Trials
Nearly every trial cited above was conducted or sponsored by PROCEPT BioRobotics, the company that makes the Aquablation device — standard practice for device trials generally, but worth knowing when a company's own pivotal trials are the primary evidence base for a procedure. This doesn't mean the results are wrong; large randomized, double-blind trials with hard safety endpoints (complication rates, reoperation rates) are much harder to manipulate than softer subjective outcomes. But it's a real reason to weight independent, non-industry replication more heavily. On that front, a UK single-center series outside the sponsored trial network — 55 consecutive patients treated with an athermal approach — found comparable IPSS and flow-rate improvements at 1 year, with sexual function preserved, reinforcing that the pivotal-trial results aren't an artifact of trial design or a specific research group [5].
What This Means If You're Weighing Your BPH Surgery Options
- •For prostates in the 50-80mL range, Aquablation has the strongest head-to-head randomized data of any newer BPH procedure — comparable-or-better symptom relief than TURP, lower complication rates, and meaningfully better ejaculation preservation, sustained to 5 years
- •For very large prostates (80mL+), Aquablation now has direct randomized comparison data against laser enucleation, not just single-arm cohort data — a genuine advance for treatment decisions in this population
- •Availability is still a real practical constraint — Aquablation requires the specific AquaBeam robotic system, so it isn't offered at every urology practice the way TURP is
- •Ask about your surgeon's case volume — as with any newer procedure, outcomes in the trials came from centers actively enrolling in and running these studies, and real-world results depend on surgeon experience with the system
- •This isn't a reason to distrust the findings, but do ask your urologist directly whether they see the trial results reflected in their own outcomes, not just cite the published numbers
Related Reading
UroLift vs. TURP vs. Rezūm: Minimally Invasive BPH Surgery Options
How Aquablation fits alongside the other BPH surgery options, including recovery time and durability comparisons.
What Is BPH? Enlarged Prostate Causes, Symptoms & Complete Overview
Background on BPH and when symptoms progress to the point where a procedure like Aquablation becomes a reasonable option.
BPH Symptoms Getting Worse: When to Escalate Treatment Before It Becomes an Emergency
How to know when medication alone isn't enough and a procedural option is worth discussing with your urologist.
Supplements for BPH Symptom Support
Super Beta Prostate Supplement
Worth discussing with your doctor as symptom support while you weigh procedural options — not a substitute for a documented, trending IPSS score.
NOW Foods Pumpkin Seed Oil
A commonly used adjunct for urinary symptom support; track your response alongside any decision about surgical timing.
Affiliate disclosure: ManCore earns a small commission on purchases made through these links at no extra cost to you.
Frequently Asked Questions
Is Aquablation better than TURP?
The 5-year randomized trial data shows comparable-or-better symptom relief, a lower complication rate, and substantially better preservation of ejaculation compared to TURP. For men with prostates 50mL or larger, symptom improvement was significantly greater with Aquablation. It isn't universally 'better' for every patient, but the evidence base is genuinely strong for these specific outcomes [1][2].
Does Aquablation preserve ejaculation better than other BPH procedures?
Yes, consistently across multiple trials. Anejaculation occurred in 10% of Aquablation patients vs. 36% with TURP, and retrograde ejaculation occurred in 14.8% of Aquablation patients vs. 77.1% with laser enucleation in a separate trial on very large prostates. This is one of the most consistently replicated findings in the Aquablation literature [1][3].
Is Aquablation good for large prostates?
This is arguably where the evidence is strongest. A direct randomized trial against laser enucleation in men with 80-180mL prostates found similar symptom relief with better ejaculation preservation and no persistent incontinence, and a separate cohort of 101 men with 80-150mL prostates showed IPSS improving from 23.2 to 6.2 at 1 year [3][4].
Who funded the Aquablation research?
Most of the pivotal trials (the WATER trial series) were conducted or sponsored by PROCEPT BioRobotics, the manufacturer of the AquaBeam Aquablation system — standard for device trials, but worth factoring in. An independent single-center UK series outside that sponsored network found comparable results, which supports the findings rather than undermining them [5].
How available is Aquablation compared to TURP?
Less available. Aquablation requires the specific AquaBeam robotic system, so it's offered at a smaller number of centers than TURP, which nearly every urology practice can perform. Ask your urologist directly whether it's available to you and how much experience their center has with the procedure.
The Bottom Line
Aquablation has something most newer BPH procedures don't: consistent, long-term randomized trial evidence against the options urologists already trust, with a genuinely well-replicated advantage in preserving ejaculatory function. The main caveat is that most of that evidence comes from trials run or funded by the device's manufacturer — worth knowing, though the hard safety and reoperation endpoints involved are harder to skew than softer outcomes, and independent replication so far backs up the pivotal trial results. If you're weighing BPH surgery options, especially with a larger prostate, it's a reasonable one to ask your urologist about directly.