Aquablation for the Treatment of BPH

Aquablation is one of the newest treatments for benign prostatic hyperplasia/BPH or enlarged prostate. BPH is a virtual certainty as patients age and excess tissue begin to build with the prostate. It is estimated that about 80% of patients over 80 will experience the symptoms associated with BPH. Early on, the signs of BPH are usually mild and force the patient to wake up in the middle of the night to urinate (nocturia), have more urgency to their urination, and urinate more frequently. Usually, the symptoms worsen over time, and at first, patients may modify their lifestyle to accommodate the difficulties associated with BPH. They may begin to have trouble urinating, feel a sense of fullness, even after voiding, experience leakage and dribbling, and worsened nocturia. Fortunately, there are plenty of viable treatment options available today.


Medication is a first-line treatment for BPH because it is easy for the patient to take, side effects are relatively low (and can be reversed with cessation), and many patients can experience excellent results, at least at first. Of course, the significant drawback of medication is that it only works for as long as the patient takes it. Further, the continued growth of prostatic tissue will make the medication less effective over time. And finally, we typically explain that medication ameliorates the problem of BPH; medication rarely completely solves the problem like procedures do.

In-office Procedures

These procedures are performed quickly and safely in the comfort of our office. Dr. Engel has previously offered TUNA (Transurethral Needle Ablation)/Prostiva and far less commonly microwave thermotherapy. However, he has now landed on REZUM water vapor (steam) BPH therapy as his preferred in-office treatment while still offering TUNA/Prostiva in more elderly patients with more severe bladder decompensation. While these in-office therapies are excellent for patients with relatively smaller prostatic anatomy and characteristics, patients with larger prostates are typically not candidates for these procedures.


For the patient with a larger prostate who has not responded or is not suited to medication or in-office therapies, we have traditionally offered a robotic simple prostatectomy or HoLEP laser therapy to open up the inside of the prostate surgically. Robotic simple prostatectomy and HOLEP are highly specialized procedures offered only by urologists with specific expertise, so they are not always widely available.  Because of this, a new technology surfaced as a tool for Urologists who do not offer these procedures to still help patients with large prostates.

Aquablation is minimally invasive and endoscopic, meaning that the entire procedure is performed with a device that accesses the prostate through the urethra. Unlike any other BPH therapy, it uses water jet technology (think of a powerful Water Pick device) to destroy prostatic tissue. While it can conceivably be used on any size prostate, its effects are best seen, and the procedure is considered safest with larger prostates – those above 80 grams. Further adding to the excitement around this procedure is that the ablation is performed entirely robotically and autonomously after the urologist and technician set the device based on the patient’s anatomy. The urologic surgeon places the device appropriately within the urethra, and the robotically controlled water jets take over.

Why Do We Not Typically Perform Aquablation?

In theory, Aquablation is an excellent concept. After all, it seems there is very little room for error as the procedure is automated. Further, using water to separate prostatic tissue mechanically appeals to urologic surgeons and their patients. However, the significant drawback is that destroyed prostatic tissue is not cauterized as it would be with both minimally invasive and surgical procedures that eliminate, ablate, or resect excess tissue. As a result, many patients experience significant bleeding after the operation that is not typically seen with robotic simple prostatectomy or HOLEP in experienced hands. This bleeding can be severe enough that patients go into shock and require blood transfusions and emergency surgeries. While this is a relatively rare outcome (perhaps 5 percent with modern modifications), it is a severe complication with an incidence far higher than that seen with other approaches, like a robotic simple prostatectomy in Dr. Engel’s hands. Patients still must have a hospitalization equivalent to the competing procedures, likely less effective long-term results, with a higher significant complication rate.  Aquablation seeks to offer the advantage of sparing the ability to ejaculate, but this is done at the expense of complete resection and, almost certainly, lesser long-term success.  We find that nearly all patients with a prostate large enough to warrant these procedures already do not have high ejaculate volume, so in practice, we do not find this to be much of an advantage.

Some urologic surgeons have now created stand-alone centers whereby an interventional radiologist performs a procedure known as PAE or Prostatic Artery Embolization to limit the amount of blood entering the prostate, thus shrinking and destroying prostatic tissue. This is mainly offered as an alternative to office therapies such as Rezum or Urolift, but at times this is done before Aquablation in the hopes of limiting some of the bleeding associated with subsequent Aquablation. We have found that the combination of performing two separate procedures under anesthesia, both with their own risks and with inferior results, does not make sense for our patients when a robotic simple prostatectomy is available.

The Bottom Line

While there is a space for novel BPH treatments, the newest and most advanced therapies sometimes fall short of their theoretical expectations. This, at least in its current form, applies to Aquablation, in Dr. Engel’s opinion, as long as a patient has access to an experienced Urologist offering robotic simple prostatectomy or HOLEP. We have followed and performed early manifestations of the technological improvements in BPH treatment over the years. For example, REZUM, a steam-based BPH procedure for prostates under 80 grams, is an excellent evolution of what was a previous mainstay of Dr. Engel’s practice, known as a TUNA or Transurethral Needle Ablation. These advances allow us to offer faster and often more effective therapies, building upon excellent technologies and results of the past. The same holds for patients with larger prostates who benefit from a simple prostatectomy or HoLEP. While these procedures are not as new and don’t leverage the degree of robotic automation that Aquablation does, they are tried and true, and their risk profile more closely matches the needs and wants of many of our patients.

For more information on BPH or enlarged prostate treatments, we encourage you to contact us and schedule an appointment with Dr. Engel.


Urologic Surgeons of Washington is a proud member of Privia Medical Group. The best doctors in our community have joined together to form Privia Medical Group (PMG), a multi-specialty, high-performance medical group that puts patients first. Our physicians are united by the mission of providing better, more coordinated care for their patients.

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