Aquablation Prostate Surgery for Enlarged Prostate

Aquablation is a robotically controlled, heat-free surgical treatment for an enlarged prostate (benign prostatic hyperplasia, or BPH). It uses a high-velocity jet of sterile water, guided by real-time ultrasound and cystoscopic imaging, to remove obstructing prostate tissue precisely. Its two defining advantages are a high rate of preserved ejaculation and a treatment time that is largely independent of prostate size — meaning it performs consistently even in large glands where other operations become slower and more difficult.

This page explains who Aquablation suits, how it compares with TURP and HoLEP, what the long-term evidence shows, and what to expect in recovery. If you would like to discuss whether it is right for you, you are welcome to arrange a consultation.

What is an enlarged prostate, and why does it cause symptoms?

The prostate sits beneath the bladder and surrounds the urethra — the tube through which urine passes. From around the age of 50, the gland commonly enlarges. This is benign (non-cancerous), but as it grows, it squeezes the urethra and obstructs the flow of urine.

The result is the cluster of symptoms urologists call lower urinary tract symptoms (LUTS): a weak or hesitant stream, the need to strain, a feeling of incomplete emptying, getting up several times at night to pass urine (nocturia), and a frequent or urgent need to go. Left untreated, severe obstruction can lead to recurrent infections, bladder stones, blood in the urine, or an inability to pass urine at all (acute retention). Y may also wish to read about my specialist LUTS and urinary symptoms clinic

Many men manage well on medication for years. When tablets stop working, cause side effects, or when complications develop, surgery to relieve the obstruction becomes the logical next step. Aquablation is one of the newer options in that surgical toolkit.

How Aquablation works

Aquablation combines two technologies that, until recently, had never been brought together in prostate surgery: precise surgical imaging and a robotically delivered waterjet.

The procedure is carried out under general or spinal anaesthetic. First, a transrectal ultrasound probe is positioned to give a live, cross-sectional view of the prostate, while a camera (cystoscope) is passed up the urethra. Using these two views together, I map the exact contour of the tissue to be removed on a console screen — and, critically, mark out the areas to be preserved, including the structures responsible for ejaculation and continence.

Once the surgical map is agreed upon, the robotic system delivers a high-pressure jet of sterile saline to remove the obstructing tissue along the planned path. The waterjet itself is non-thermal, meaning it removes tissue mechanically rather than by burning or lasering it. This may reduce the risk of thermal injury to surrounding structures and is one reason Aquablation has attracted interest as an ejaculation-preserving option. Bleeding is still carefully controlled during the operation, sometimes using focal cautery where needed.

The tissue-removal phase, known as resection, typically takes only a few minutes. Any minor bleeding is then controlled, and a catheter is left in place for a short time while the area heals.

The two things that make Aquablation different

1. It preserves ejaculation in most men

For many men, this is the deciding factor. Conventional prostate surgery frequently causes retrograde ejaculation, where semen passes backwards into the bladder rather than out — a permanent change that affects sexual function and fertility.

Because Aquablation can spare the specific zone near the bladder neck responsible for ejaculation, ejaculatory function is preserved in the large majority of men.

In the WATER randomised trial, procedure-related ejaculatory dysfunction was significantly lower after Aquablation than after TURP. Some contemporary real-world series have reported very high rates of preserved antegrade ejaculation, but the individual risk depends on prostate anatomy, surgical planning and the extent of treatment required.

2. Its results don’t fall off in larger prostates

With most operations, a bigger prostate means a longer, more technically demanding procedure and a higher complication rate. Aquablation’s resection time depends far less on gland size because the robot follows a pre-planned map at a consistent rate.

The waterjet resection phase is relatively predictable and less dependent on prostate size than many conventional resection techniques, although total operating time and recovery still depend on gland size, anatomy and bleeding control.

This makes it a genuinely attractive option for men with large glands — the WATER II trial specifically studied prostates measuring 80–150 mL and reported durable results for up to 5 years.

What the evidence shows

Aquablation is now supported by a substantial and maturing body of clinical evidence, not a handful of early case reports.

• The WATER trial was a double-blind, randomised study comparing Aquablation directly against TURP — the long-standing surgical benchmark. Five-year outcomes showed comparable, durable symptom relief, with a markedly lower rate of ejaculatory dysfunction after Aquablation.
• The WATER II trial focused on large prostates (80–150 mL) and confirmed sustained improvements in symptoms and flow at 5 years, with a low retreatment rate.
• Real-world registry data from the international ICARUS collaboration, spanning thousands of men treated across Asia, Europe and North America between 2019 and 2024, has confirmed a low overall rate of serious bleeding (transfusion or return to theatre) across a wide range of prostate sizes — supporting both the safety profile and the broad applicability seen in the trials.

In practical terms, a typical man can expect his International Prostate Symptom Score (IPSS) to fall substantially, his urinary flow rate to improve, and that improvement to hold up over years rather than months.

In the UK, NICE guidance supports transurethral water-jet ablation for LUTS caused by BPH with standard arrangements for clinical governance, consent and audit.

Who is Aquablation suitable for?

Aquablation may be a strong option if you:

• have moderate to severe urinary symptoms from BPH that medication no longer controls;
• have a larger prostate, where you have been told other operations would be lengthy or higher-risk;
• place a high value on preserving ejaculatory function;
• want a treatment with durable, evidence-backed results.

It may be less suitable, or need careful discussion, if you have certain anatomical factors, are unable to stop blood-thinning medication, or have prostate cancer requiring different treatment. (Aquablation for prostate cancer is being studied in the WATER IV trial, but is not standard care — for BPH, it is an established option.)

The honest answer is that no single operation is best for every man. The right choice depends on your prostate size and shape, your symptoms, your general health, your priorities around sexual function, and your own preferences after a full discussion of the trade-offs. That conversation is exactly what a consultation is for.

How I assess whether Aquablation is right for you

Suitability depends on more than prostate size alone. I usually assess symptom severity, urinary flow rate, post-void residual volume, PSA history, prostate imaging, cystoscopy findings where appropriate, general anaesthetic fitness, bladder function and medication history, including blood thinners. This allows us to fairly compare Aquablation with alternatives such as TURP, HoLEP, Rezūm, UroLift, GreenLight laser, prostate artery embolisation, or simple prostatectomy.

How Aquablation compares with other procedures

Feature	Aquablation	TURP	HoLEP
Mechanism	Heat-free robotic waterjet	Electrical heat resection	Laser enucleation
Ejaculation preserved	In most men	Often lost	Often lost
Performance in large glands	Consistent	Slower, higher risk	Effective but technically demanding
Evidence base	Randomised + 5-yr data	Decades (the benchmark)	Strong, mature
Typical hospital stay	Short	Short	Short

TURP remains the benchmark against which new procedures are measured, and HoLEP is an excellent, durable operation in experienced hands. Aquablation’s distinct niche is the combination of ejaculation preservation and consistent performance in larger prostates.

Recovery and what to expect after aquablation

Most men stay in hospital for a short period, often overnight, with a catheter in place to allow the prostate to settle. The catheter is usually removed within a day or two, after which you can pass urine normally.

In the first couple of weeks, it is common to notice some blood in the urine, a degree of urinary urgency or stinging, and the need to take things gently. These settle as the area heals. I advise avoiding heavy lifting and strenuous exercise for a short period and staying well hydrated. Most men return to normal daily activities within a couple of weeks, with the full benefit of improved flow developing over the following weeks and months.

I will give you specific, written aftercare guidance tailored to your operation, and arrange follow-up to confirm that your symptoms and flow have improved as expected.

After Aquablation, some blood in the urine, urgency and mild stinging can be normal in the early recovery period. However, you should seek urgent medical advice if you are unable to pass urine, pass large clots, develop a fever, have worsening pain, or if bleeding becomes heavy or persistent.

Frequently asked questions

Discuss Aquablation with Mr Haldar

If you are weighing up treatment for an enlarged prostate and want to understand whether Aquablation is the right choice for you, I would be glad to see you. I consult across the Thames Valley and can talk you through all the options — not just this one — so that your decision is fully informed.

Mr Neil Haldar is a Consultant Urological Surgeon (GMC 3683914). This article is general information and not a substitute for individual medical advice.

Further Reading

The British Association of Urological Surgeons (BAUS) Aquablation Information Leaflet