The waterjet ablation (Aquabeam®) for treatment of symptomatic benign prostatichyperplasia: 3-years functional outcomes from a large Italian series (>200 cases)

The waterjet ablation (Aquabeam®) for treatment of symptomatic benign prostatichyperplasia: 3-years functional outcomes from a large Italian series (>200 cases) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The waterjet ablation (Aquabeam ® ) for treatment of symptomatic benign prostatichyperplasia: 3-years functional outcomes from a large Italian series (>200 cases) Angelo Porreca, Daniele D'Agostino, Gian Maria Busetto, Antonio Amodeo, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6539530/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) significantly affect the quality of life in men. Traditional surgical treatments offer symptom relief but may contribute to sexual dysfunction. Waterjet ablation, or Aquablation, is a minimally invasive technique, alternative to standard Holmium-laser enucleation of prostate (HoLEP), that uses high-pressure water to ablate prostatic tissue, offering both functional and sexual advantages. This study aimed to evaluate the three-year functional outcomes of Aquabeam® waterjet ablation for the treatment of bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH). We focused on measuring changes in urinary symptoms, quality of life, continence, and ejaculatory function, along with the incidence of complications. Methods We conducted a retrospective analysis from a prospectively maintained database of 218 consecutive BPH patients treated with Aquabeam® waterjet ablation. The procedures were performed between January 2019 and January 2022 across three referral centers for BPH management. Functional outcomes were evaluated pre- and post-operatively and included International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), post-void residual urine (PVR), continence status, sexual function, and ejaculatory function. The median follow-up was 3 years. Results The median age of patients at surgery was 61 years (IQR: 57–66), with median PSA levels of 2.52 ng/mL (IQR: 0.4–21.6) and a median prostate volume of 55 mL (IQR: 40–73). The median operative time was 56 minutes (IQR: 20–168), with a median catheterization time of 48 hours (IQR: 24–480) and a hospital stay of 48 hours (IQR: 24–600). At 3-year follow-up, patients experienced significant symptom relief, with a median IPSS score of 5 (IQR: 3–21) and a Qmax of 18 mL/s (IQR: 9–26). These results were significantly better than baseline scores, observed as early as three months post-procedure, and remained stable throughout the follow-up period. The continence rate was 100%, and the ejaculation preservation rate was 87%, with a positive trend over time. Complications were classified according to the Clavien-Dindo system: 8.3% of patients experienced Grade 1 complications (18 patients), 11.9% had Grade 2 (26 patients), and only 0.5% encountered Grade 3 complications. All complications were temporary and resolved completely without any long-term effects. Conclusions The Aquabeam® waterjet ablation procedure was safe, effective, and reproducible, offering clinically meaningful improvement in LUTS and quality of life for BPH patients. Its ability to preserve ejaculation in a high percentage of patients underscores its advantage over traditional methods. These medium-term outcomes are promising, although further research into long-term durability is necessary to confirm the sustained benefits of the procedure. Aquablation waterjet ablation benign prostatic hyperplasia LUTS bladder outlet obstruction ejaculatory preservation medium-term outcomes Aquabeam Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Benign prostatic hyperplasia (BPH) is a common condition in aging men, characterized by the non-cancerous enlargement of the prostate gland, which often leads to bladder outlet obstruction (BOO) and lower urinary tract symptoms (LUTS). These symptoms have a significant negative impact on quality of life, affecting sleep, daily activities, and overall well-being. Standard surgical treatment, such as Holmium-laser enucleation of prostate (HoLEP), is effective in reducing LUTS but lead to loss of ejaculatory function [ 1 ]. In recent years, the Aquablation technique, based on waterjet ablation technology, emerged as a minimally invasive alternative for managing BOO caused by BPH. Aquablation uses high-pressure water to precisely ablate prostatic tissue, allowing for targeted removal with minimal damage to surrounding structures. This approach aims to offer relief from LUTS while preserving key aspects of sexual function, particularly ejaculation, which is a common concern for patients undergoing traditional BPH treatments [ 2 , 3 ]. In the last years, Aquablation treatment was compared to the standard approaches (HoLEP and trans-urethral resection of prostate – TURP), and the non-inferiority was demonstrated Aquablation proved to be a valid alternative to standard resection techniques [ 4 ] and recently also to enucleation techniques [ 5 , 6 ], showing excellent long-term functional outcomes, good preservation of sexual function, a good safety profile, and good compliance for all prostate sizes and patient ages. According to EAU guideline, Aquablation appeared non-inferior in terms of functional outcomes in patients with BOO caused by 30–80 ml BPH (level of evidence: 1b) compared to TURP, and it was indicated as an alternative even if with a weak strength rate. Moreover, there are still concerns about management of bleeding [ 1 ]. Therefore, Aquablation remains under investigation, as the evidence levels described by Speakman et al. [ 7 ] have not yet been reached. This study provides a comprehensive analysis of the three-year outcomes of Aquabeam® waterjet ablation in a cohort of patients treated for BPH-induced BOO. By evaluating changes in urinary symptoms, quality of life, and functional outcomes - including continence and ejaculatory function - this study seeks to assess the safety, efficacy, and durability of Aquablation over a medium-term follow-up period. Through these findings, we aimed to contribute valuable insights into the role of Aquablation in the evolving landscape of BPH management and to guide clinicians in making informed treatment decisions for patients with BPH. Methods Study population The study was based on a retrospective analysis of 218 consecutive patients (Fig. 1 ) with BOO due to BPH who were treated with Aquabeam® waterjet ablation between January 2019 and January 2022. All procedures were conducted across three high-volume referral centers specialized in BPH management. Patient data were obtained from a prospectively maintained database to ensure consistency and accuracy in data collection. Study design Multi-centric, non-controlled, observational, retrospective based on prospectively maintained database study. Inclusion/exclusion criteria Patients included in the study were adult men diagnosed with symptomatic BPH, confirmed through clinical evaluation, imaging (axial and sagittal ultrasound imaging of prostate gland, multiparametric MRi of prostate if indicated in the definition of the PSA increase), and laboratory tests (urine test, urine culture, free and total PSA, renal function tests), complete 36-monthsd follow-up. Criteria for inclusion were: presence of LUTS unresponsive to medical therapy, evidence of BOO based on clinical findings, patient's willingness to save ejaculation, complete follow-up, signed informed consent. Exclusion criteria included prior prostate surgery, prostate cancer diagnosis, severe medical comorbidities that would contraindicate the procedure, previous pelvic radiotherapy, previous systemic chemotherapy, known immune deficiency, active/uncontrolled urinary infections, liver, kidney, or hematologic function disorders, coexistence of tumors, and inability to participate. Procedure All Aquabeam® waterjet ablation procedures were performed under general or spinal anesthesia, with patients positioned in lithotomy. The Aquabeam® device was used to deliver high-velocity waterjets, allowing precise and controlled ablation of the targeted prostatic tissue while sparing surrounding structures. This technique utilizes real-time imaging and robotic assistance to minimize the risks of damage to adjacent tissues. After the ablation, the “fluffy” tissue was removed by a loop, and subsequently the hemostasis was performed by bipolar energy [ 8 ]. Operative time, catheterization duration, and length of hospital stay were recorded as part of procedural data. Measurements Functional outcomes were evaluated pre-operatively and at multiple post-operative time points (3 months, 1 year, and annually up to 3 years post-surgery). The following measures were assessed: the IPSS (to quantify the severity of urinary symptoms, with scores categorized as mild, moderate, or severe); the maximum Urinary Flow Rate (Qmax) (measured using uroflowmetry to assess urinary flow dynamics; an increase in Qmax was considered indicative of improved urinary function); the Post-Void Residual (PVR) (measured via ultrasound to determine the amount of urine remaining in the bladder after voiding, with lower values suggesting improved bladder emptying); the Continence status (evaluated based on patient-reported continence levels and the need for any incontinence aids or medications); a specific focus on sexual function was given to rates of ejaculation preservation, an important consideration in BPH treatment. Complications following the Aquabeam® waterjet ablation procedures were systematically documented and classified using the Clavien-Dindo classification system [ 9 ], a standardized grading system for surgical complications based on the level of intervention required for resolution. This classification facilitates objective and consistent reporting of post-operative complications across clinical studies. Grade 1 Complications were defined as any deviation from the normal post-operative course not requiring pharmacological treatment or surgical intervention. Grade 2 Complications require pharmacological treatment, such as antibiotics, analgesics, or anti-inflammatory drugs, without necessitating invasive procedures. Grade 3 Complications involve those requiring surgical, endoscopic, or radiological intervention. Data Analysis The sample size and the relative statistical power of the study were not calculated due to the nature of the study. Descriptive statistics were employed to summarize patient demographics and baseline characteristics. Median values with interquartile ranges (IQR) were used for continuous variables, while categorical variables were expressed as percentages. Changes in outcome measures over time were assessed using paired statistical tests to compare pre-operative and post-operative values. Parametric and nonparametric variables were evaluated using ANOVA and Kruskal-Wallis, respectively. Statistical significance was defined as a two-sided p-value < 0.05. We conducted all analyses using statistical software STATA/SE version 18 (StataCorp, College Station, TX, USA). Follow-Up and Data Collection Patients were followed up at regular intervals, with the primary endpoint at 3 years post-surgery. Follow-up included physical examination, symptom assessment, and objective testing. Complications were documented and classified according to the Clavien-Dindo grading system, with attention to both short-term and long-term adverse effects. Results Baseline The median age of patients was 61 years (IQR: 57–66). Preoperative median PSA level was 2.52 ng/mL (IQR: 0.4–21.6), reflecting a population with varied baseline prostate function. The median prostate volume measured via ultrasound was 55 mL (IQR: 40–73) (table 1, Fig. 7 ). Operative Data The median operative time was 56 minutes (IQR: 20–168) (Fig. 4 ), the median catheterization time was 2 days (IQR: 1–7), with the majority of patients achieving adequate voiding function shortly after removal. The length of hospital stay varied from 1 to 5 days, with a median stay of 2 days, indicating that most patients were discharged within 48 hours of the procedure (table 2). Functional Outcomes At the 3-years follow-up, Aquabeam® demonstrated significant and durable improvements in key functional outcomes: Urinary Symptoms (IPSS): The median IPSS decreased from baseline, with patients reporting a median IPSS score of 5 (IQR: 3–21). This marked improvement was evident as early as 3-months post-procedure and remained stable throughout follow-up, highlighting the efficacy of Aquabeam® in symptom management (Fig. 2 ). Qmax: Patients experienced an increase in urinary flow rate, with a median Qmax of 18 mL/s (IQR: 9–26). This value represented a substantial improvement over baseline Qmax values, with gained in flow rate observed as early as three months post-operatively and sustained throughout follow-up (Fig. 4 ). Continence and Ejaculatory Function: the continence rate remained at 100% at 3-years; the ejaculatory function was preserved in 87% of patients, with an increasing trend toward preservation over time (Fig. 6 ). - Complications: 8.3% of patients (18 patients) experienced Grade 1 complications, including mild hematuria and dysuria, which were self-limiting and managed conservatively. Grade 2 complications were reported in 11.9% of patients (26 patients), most commonly urinary tract infections (UTIs) and symptomatic inflammation, both of which resolved with standard pharmacological treatment. Only 1 patient (0.5%) had a Grade 3 complication, which required temporary catheter re-insertion; this patient recovered fully, with no long-term complications reported. Eight patients (3.7%) experienced urinary retention and required the temporary catheter re-insertion (for a week) and all of them fully recovered without long-term complications. Importantly, all complications were temporary and resolved completely, supporting the safety profile of Aquabeam® in this patient population. Discussion This study reinforced the growing body of literature that supports Aquabeam® waterjet ablation as a minimally invasive and effective treatment option for managing LUTS due to BPH. The study’s three-year follow-up data confirmed substantial improvements in functional outcomes and a favorable safety profile, underscoring Aquabeam® as a strong alternative to traditional treatments, which often pose greater risks, including ejaculatory and sexual dysfunction. The observed improvements in functional outcomes, including the reduction in IPSS and increases in Qmax, aligned with findings from major studies like WATER [ 10 ] and WATER II [ 11 ], as well as data from the recent meta-analysis by Elterman and colleagues [ 12 ]. In our cohort, the median IPSS at the 36-month follow-up was significantly reduced, with a median score of 5 (IQR: 3–21), a result that resonates with the meta-analysis and WATER trial outcomes, which reported IPSS reductions of 15 to 17 points and sustained improvements at long-term follow-up [ 13 , 14 ]. In WATER II, after twelve months, significant improvements were seen in IPSS (mean decrease of 17 points), Qmax (increase of 12.5 cc/sec) and PVR (a drop of 171 cc in those with PVR > 100 at baseline). At 5-years follow-up, 3% of patients required surgical retreatment [ 15 ], differently from our study were no patients needed to be retreated In the pivotal double-blind, multicenter RCT comparing Aquablation to transurethral resection of the prostate (TURP), IPSS reductions were similar between groups, with no significant difference in improvements in IPSS, Qmax, and post-void residual (PVR) after six months. Urodynamic studies of 66 patients enrolled in the WATER trial at six months follow-up showed significant changes in pdetQmax (reductions of 35 and 34 cm H20, respectively) and large improvements in BOO index in both groups [ 15 ]. The present study further supports these findings, with sustained IPSS and Qmax improvements over three years, indicating robust symptom relief in patients with a range of prostate sizes. Additionally, Aquablation maintained lower resection times (4 vs. 27 minutes for TURP), an advantage that may contribute to a quicker recovery and less tissue trauma. One of Aquabeam®’s most compelling benefits is its preservation of ejaculatory function, a critical factor for many patients when selecting a treatment for BPH. In our cohort, 87% of patients maintained ejaculation three years post-treatment, closely aligning with findings from the WATER [ 10 ] and WATER II [ 11 ] trials, which reported ejaculatory preservation rates of 85% or higher. In contrast, TURP often has a high incidence of ejaculatory dysfunction, with the pivotal RCT noting rates of anejaculation at 36% for TURP versus 10% for Aquablation. This difference, further corroborated by the meta-analysis, highlights Aquabeam®’s advantage in minimizing sexual side effects. This outcome can be attributed to the precise tissue ablation technique of Aquablation, which minimizes neurovascular damage, preserving sexual function while providing effective LUTS relief. The safety profile of Aquabeam® observed in this study is consistent with findings from other studies, including the WATER trials and the meta-analysis. Most complications were minor (Clavien-Dindo Grades 1 and 2) and transient, with very few instances of Grade 3 complications, underscoring Aquabeam®’s minimally invasive nature. The WATER trial indicated a lower rate of persistent adverse events in the Aquablation group compared to TURP, further supporting its safety profile. Bleeding-related events were noted in WATER II, where 13.9% of patients required intervention, yet the overall transfusion rate was low. Results for the WATER trial have shown comparable hospital stay and catheterisation duration (1.4 and 1 day, respectively) [ 10 ]. One case of blood transfusion was reported after Aquabeam and none after TURP. In a systematic review of seven patient groups involving 446 patients treated by aquablation, although there was a significant haemoglobin drop (2.06 g/dL), it did not translate into increased transfusion rates. In WATER, fewer men in the Aquablation group had a persistent Clavien-Dindo grade 1 or 2 or higher adverse event compared to TURP (26% vs. 42%) at three months. In patients with a prostate volume between 80–150 mL (WATER II trial), bleeding related events were observed in fourteen patients (13.9%) of which eight (7.9%) occurred prior to discharge and six (5.9%) occurred within one month of discharge. Blood transfusions were required in eight patients, return to the theatre for fulguration in three patients, and both transfusion and fulguration in two patients [ 16 ]. Maintenance of antegrade ejaculation was slightly lower in WATER II at 81% compared to 90% in the smaller prostates of WATER I [ 17 ]. In WATER II there was a 2% de novo incontinence rate at twelve months [ 18 ]. In terms of procedural metrics, this study’s median operative time (56 minutes) (Fig. 5 ), catheterization duration, and hospital stay (2 days) were also in line with those observed in WATER and WATER II, where operative times were similarly brief, indicating the efficiency and minimally invasive nature of Aquabeam®. Furthermore, our study's transfusion rate was similarly low, aligning with data from a systematic review that demonstrated an acceptable hemoglobin drop (2.06 g/dL), with minimal impact on transfusion rates. Both this study and the meta-analysis suggest Aquablation’s durable improvements in IPSS and Qmax over three to five years. In WATER [ 10 ] and WATER II [ 11 ] trials, IPSS improvements remained steady over five years, and Qmax improvements were 125% for Aquablation compared to 89% for TURP. While the surgical retreatment rate was slightly higher for Aquablation (5.1%) compared to TURP (1.5%), Aquablation still offers a compelling alternative, particularly for patients who prioritize ejaculatory function preservation. Notably, retreatment rates in larger prostates (WATER II cohort) were as low as 3% at five years, suggesting Aquablation’s potential efficacy in anatomically challenging cases. In an analysis of procedural differences including data from WATER I and II, compared to a single pass of ablation, the use of two or more passes during Aquablation resulted in lower IPSS scores by four points, and lower IPSS QoL scores by 0.7 points at 24 and 36 months. Similarly, 36-month Qmax values were higher by 5 ml/sec in those with two or more passes than in those with one pass [ 19 ]. In our experience, we generally performed a second or more treatment passes according the on-site modification of the prostate glad after the first treatment pass, in order to obtain a better ablation and therefore a higher improvement of functional outcomes; this was based even on Bach et al. [ 19 ] study where independently from the prostate volume, a multiple treatment pass protocol led to improved voiding outcomes and IPSS improvement, without negative effect on ejaculatory function. In the initial findings of the multicentre Randomized-Controlled WATER III Trial, Aquablation was compared to HoLEP, and the therapy delivered similar symptom score reduction, superior ejaculatory function preservation, and superior continence preservation to laser enucleation in 80–180 mL prostates. The WATER III represented a significant milestone with 3-month results demonstrating similar symptom relief while showing significantly lower rates of ejaculatory dysfunction (14.8% vs. 77.1%) and stress incontinence (0% vs. 9.1%) compared to laser enucleation, and with Aquablation procedural transfusion rate at 0% [ 5 , 6 ]. Our data appeared comparable to this multicenter study, giving value to our findings. One of the issue of this technique is about the bleeding and the management of cautery after the ablation. In a study on the short-term functional outcomes and the efficacy of hemostasis performed with holmium laser after the prostatic hydroablation, D’Agostino et al. showed a low rate of complications for the combined approach for hemostasis and encouraged the functional results confirming the safety of this technique. [ 20 ]. Busetto et al. reported that short-term treatment with dutasteride was able to reduce operative and perioperative bleeding in patients with large prostates (≥ 50 mL) undergoing bipolar TURP [ 21 ]; otherwise, it is not yet clear whether 5α-Reductase inhibitors (5-ARIs) therapy can influence perioperative and functional outcomes after Aquablation. Furthermore, it is currently unclear whether chronic bacterial prostatitis and its different antibiotic / non-antibiotic treaTment can influence the outcome after ablation [ 22 ]; these data are currently absent, but surely a sub-analysis of these data should be warranted for an increasingly personalized treatment of Aquablation. Limitations This study, while providing valuable insights into the medium-term efficacy and safety of Aquabeam® waterjet ablation for treating bladder outlet obstruction (BOO) in patients with benign prostatic hyperplasia (BPH), has several limitations that should be acknowledged. Firstly, this was a retrospective analysis, which inherently introduces potential biases related to patient selection and data collection. Although data were prospectively maintained, the absence of randomization limits the ability to control for confounding factors that might affect outcomes, such as baseline patient characteristics or variations in technique across centers. Secondly, the follow-up period was limited to a median of three years. While this timeframe allows for meaningful assessment of medium-term outcomes, it does not provide information on the long-term durability of Aquabeam® waterjet ablation. Consequently, further studies with extended follow-up periods are necessary to determine whether the functional improvements and high ejaculation preservation rates observed in this study are sustained over time. Additionally, this study did not include a control group of patients undergoing alternative treatments for BPH, such as transurethral resection of the prostate (TURP) or laser-based procedures, limiting direct comparisons. A comparative study design would help clarify the relative advantages and disadvantages of Aquabeam® waterjet ablation against established treatment options, particularly regarding outcomes like symptom relief, complication rates, and preservation of sexual function. Despite the high preservation rate indicates that patients maintained relatively stable ejaculatory function following the Aquabeam® procedure, the specific quantitative MSHQ-EjD scores were not provided in the study summary. Further studies with detailed MSHQ-EjD scores could provide additional insights into the specific aspects of ejaculatory function preserved with Aquabeam® over a longer-term follow-up. Lastly, while the study reported low rates of complications and successful resolution of all adverse events, the sample size may still be insufficient to capture rarer but potentially significant complications or adverse effects. Larger multicenter studies or meta-analyses would provide a more comprehensive safety profile of the procedure. In summary, while the results of this study are promising, its retrospective nature, lack of long-term data, absence of a comparative group, and potential underrepresentation of rare complications indicate that further randomized, controlled studies with extended follow-up are warranted to fully establish the clinical value and durability of Aquabeam® waterjet ablation in the management of BPH. Conclusions The findings from this study indicate that Aquabeam® waterjet ablation is a safe and effective treatment for managing bladder outlet obstruction due to benign prostatic hyperplasia, with significant and sustained improvements in LUTS over a three-year period. Aquabeam® was associated with high rates of continence preservation and a notable ejaculation preservation rate of 87%, highlighting its potential as a preferred option for patients seeking relief from BPH symptoms with minimal impact on sexual function. The procedure also showed a low incidence of complications, which were generally mild and fully resolved without long-term sequelae. These results underscore Aquabeam® as an established, minimally invasive alternative to traditional surgical options of HoLEP in case of patients willing to preserve the ejaculatory function, providing relief from urinary symptoms while preserving quality of life. While the medium-term outcomes are encouraging, further studies with longer follow-up are essential to validate the durability of these benefits over time and to establish Aquabeam® as a standard treatment option for BPH as alternative to HoLEP. Declarations Author Contributions: Conceptualization: P.A., D.L., D'A.D.; methodology: M.F., De.D.; validation: M.F., S.F.; formal analysis: M.F., S.F.; investigation: D.L.; resources: A.A., C.F.; data curation: D.L.; writing—original draft preparation: D.L., M.F.; writing—review and editing: D.D., B.G.M.; visualization: De.D., G.M., A.A., C.F.; supervision: P.A.. All authors have read, reviewed and agreed to the published version of the manuscript. Funding: This research did not receive any funding to cover publication costs. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the Humanitas Gavazzeni e Castelli for studies involving humans. Informed Consent Statement: Written informed consent has been obtained from the patients to publish this paper. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Acknowledgments: None. Conflicts of Interest: The authors declare no conflicts of interest. References Management of Non-neurogenic Male LUTS EAU Guidelines. Edn. presented at the EAU Annual Congress Paris April 2024. ISBN 978-94-92671-23-3 MacRae C, Gilling P (2016) How I do it: Aquablation of the prostate using the AQUABEAM system. 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BMJ Surg Interv Health Technol 3(1):e000090. 10.1136/bmjsit-2021-000090 PMID: 35047807; PMCID: PMC8749268 Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Aho T, Kramolowsky E, Thomas A, Cowan B, Roehrborn C (2019) Randomized Controlled Trial of Aquablation versus Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia: One-year Outcomes. Urology 125:169–173 Epub 2018 Dec 12. PMID: 30552937 Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Aho T, Kramolowsky E, Thomas A, Kaufman RP Jr, Badlani G, Plante M, Desai M, Doumanian L, Te AE, Roehrborn CG (2022) Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol 29(1):10960–10968 Pimentel MA, Yassaie O, Gilling P (2019) Urodynamic Outcomes After Aquablation. Urology 126:165–170. 10.1016/j.urology.2019.01.020 Epub 2019 Feb 2. PMID: 30721737 Desai M, Bidair M, Zorn KC, Trainer A, Arther A, Kramolowsky E, Doumanian L, Elterman D, Kaufman RP Jr, Lingeman J, Krambeck A, Eure G, Badlani G, Plante M, Uchio E, Gin G, Goldenberg L, Paterson R, So A, Humphreys M, Roehrborn C, Kaplan S, Motola J, Bhojani N (2019) Aquablation for benign prostatic hyperplasia in large prostates (80–150 mL): 6-month results from the WATER II trial. BJU Int 124(2):321–328. 10.1111/bju.14703 Nguyen DD, Barber N, Bidair M, Gilling P, Anderson P, Zorn KC, Badlani G, Humphreys M, Kaplan S, Kaufman R, So A, Paterson R, Goldenberg L, Elterman D, Desai M, Lingeman J, Roehrborn C, Bhojani N (2020) Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30–80 and 80–150 mL prostates. BJU Int 125(1):112–122. 10.1111/bju.14917 Bhojani N, Bidair M, Zorn KC, Trainer A, Arther A, Kramolowsky E, Doumanian L, Elterman D, Kaufman RP, Lingeman J, Krambeck A, Eure G, Badlani G, Plante M, Uchio E, Gin G, Goldenberg L, Paterson R, So A, Humphreys M, Kaplan S, Motola J, Desai M, Roehrborn C (2019) Aquablation for Benign Prostatic Hyperplasia in Large Prostates (80–150 cc): 1-Year Results. Urology 129:1–7. 10.1016/j.urology.2019.04.029 Bach T, Barber N, Elterman D, Humphreys M, Bhojani N, Zorn KC, Te A, Chugtai B, Kaplan S (2022) Aquablation Outcomes in Men With LUTS Due to BPH Following Single Versus Multi-pass Treatments. Urology 169:167–172. 10.1016/j.urology.2022.07.007 D'Agostino D, Colicchia M, Corsi P, Romagnoli D, Del Rosso A, Modonutti D, Busetto GM, Ferro M, Schiavina R, Molinaroli E, Artibani W, Porreca A (2021) The combination of waterjet ablation (Aquabeam®) and holmium laser power for treatment of symptomatic benign prostatic hyperplasia: early functional results. Cent Eur J Urol 74(2):222–228. 10.5173/ceju.2021.0049 Busetto GM, Giovannone R, Antonini G, Rossi A, Del Giudice F, Tricarico S, Ragonesi G, Gentile V, De Berardinis E (2015) Short-term pretreatment with a dual 5α-reductase inhibitor before bipolar transurethral resection of the prostate (B-TURP): evaluation of prostate vascularity and decreased surgical blood loss in large prostates. BJU Int 116(1):117–123. 10.1111/bju.12917 Epub 2015 Jan 21. PMID: 25291499 Busetto GM, Giovannone R, Ferro M, Tricarico S, Del Giudice F, Matei DV, De Cobelli O, Gentile V, De Berardinis E (2014) Chronic bacterial prostatitis: efficacy of short-lasting antibiotic therapy with prulifloxacin (Unidrox®) in association with saw palmetto extract, lactobacillus sporogens and arbutin (Lactorepens®). BMC Urol 14:53. 10.1186/1471-2490-14-53 PMID: 25038794; PMCID: PMC4108969 Tables Table 1. Baseli MEDIAN IQR RANGE Age 61 57-66 44-80 PRE-OP prostate volume, ml 55 40-73 22-200 presence of middle lobe, yes/no (%) 92/126 (42,2%) Qmax, ml/s 9 6,2-11 2-17 tPSA, ng/ml 2,52 0,4-21,6 1,59-4,27 Post-void residual, ml 90 72,5 0-420 presence of bladder lithiasis, yes/no (%) 4/218 (1,8%) IPSS 19 0-35 15-23 QoL 4 3-6 4-5 Indwelling bladder catheter, yes/no (%) 1/218 Urinary incontinence, yes/no 7/211 stress 0/7 urge 7/7 Pad, yes/no (%) 2/216 Hemoglobin, g/dl 15,2 10,7-17,1 14,4-15,7 medications, yes/no 201/17 alfa-blocker 167 5-ARI 14 combined 20 ne characteristics Table 2. Peri-o SURGERY MEDIAN IQR Operation time (minutes) 56 20-168 hystology, yes/no (%) performed/not performed 46/172 negative for cancer 45/46 pT1a 1/46 Complications early, yes/no (%) 7/211 bleeding 4/7 blood tranfusion 2/7 rectal injury 1/7 late, yes/no (%) 3/215 bladder neck sclerosis 1/3 urethral stenosis 2/3 POST-OP Hemoglobin, g/dl 14 9,2-17 Time of catheterization, days 2 1-7 Time of hospitalization, days 2 1-5 urinary incontinence at discharge, yes/no (%) 0/218 perative data Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6539530","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":463814352,"identity":"d7182ff1-aa97-46b1-967a-6afe9f05c271","order_by":0,"name":"Angelo Porreca","email":"","orcid":"","institution":"Humanitas Gavazzeni","correspondingAuthor":false,"prefix":"","firstName":"Angelo","middleName":"","lastName":"Porreca","suffix":""},{"id":463814353,"identity":"6c4cb01a-21a1-41d9-be3c-e7109f3dc99b","order_by":1,"name":"Daniele D'Agostino","email":"","orcid":"","institution":"Villa Salus","correspondingAuthor":false,"prefix":"","firstName":"Daniele","middleName":"","lastName":"D'Agostino","suffix":""},{"id":463814354,"identity":"efe626fe-af93-47c8-a6d7-827f35d2c479","order_by":2,"name":"Gian Maria Busetto","email":"","orcid":"","institution":"University of Foggia","correspondingAuthor":false,"prefix":"","firstName":"Gian","middleName":"Maria","lastName":"Busetto","suffix":""},{"id":463814355,"identity":"61139c1f-af7c-44e5-a700-72f7a63a310c","order_by":3,"name":"Antonio Amodeo","email":"","orcid":"","institution":"Istituto Oncologico Veneto","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Amodeo","suffix":""},{"id":463814356,"identity":"8c6a00e1-1d06-47b7-b6bc-2772aeeb82da","order_by":4,"name":"Francesco Claps","email":"","orcid":"","institution":"Istituto Oncologico 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Gianfrancesco","email":"","orcid":"","institution":"Humanitas Gavazzeni","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"Di","lastName":"Gianfrancesco","suffix":""}],"badges":[],"createdAt":"2025-04-27 09:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6539530/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6539530/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83784751,"identity":"06ba4e3a-a08f-4ddf-971a-32a00c862863","added_by":"auto","created_at":"2025-06-02 16:31:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41786,"visible":true,"origin":"","legend":"\u003cp\u003eFlow-chart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/3bf13ff558d76d03c7c0c381.png"},{"id":83785630,"identity":"ec583a01-df16-4476-bc2e-879baa3048ce","added_by":"auto","created_at":"2025-06-02 16:47:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46176,"visible":true,"origin":"","legend":"\u003cp\u003eTotal PSA trend\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/1ca104da7624197d7f085996.png"},{"id":83784748,"identity":"caf38bb7-64cb-4ca8-b438-d0ecce8832bc","added_by":"auto","created_at":"2025-06-02 16:31:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":19829,"visible":true,"origin":"","legend":"\u003cp\u003eTotal PSA trend\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/fe22867e8c1ee0534e6b8000.png"},{"id":83785631,"identity":"7ee91686-479d-4ff6-859a-29ed3db0453a","added_by":"auto","created_at":"2025-06-02 16:47:23","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":22451,"visible":true,"origin":"","legend":"\u003cp\u003eQmax trend\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/2f80cf9953c83c3188fa2428.png"},{"id":83784758,"identity":"966e7871-a7fe-4acf-b6be-de39ca756a2c","added_by":"auto","created_at":"2025-06-02 16:31:23","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":109185,"visible":true,"origin":"","legend":"\u003cp\u003eOperative time\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/24b7b51ed5a3cf81b2c6851e.png"},{"id":83784757,"identity":"b5981136-86f5-43de-9ae7-03d855ef36d6","added_by":"auto","created_at":"2025-06-02 16:31:23","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":47730,"visible":true,"origin":"","legend":"\u003cp\u003eEjaculatory function preservation rate.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/2713799777d47942183fbee1.png"},{"id":83784754,"identity":"8fcc4c67-dc2f-44d8-a6d0-4ce7b3ce62d6","added_by":"auto","created_at":"2025-06-02 16:31:23","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":27322,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of patients according the prostate volume\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/9f33f56e4af16be7d22a7c95.png"},{"id":84665925,"identity":"5ca612fb-cb14-4217-b755-0d6f0774e0a5","added_by":"auto","created_at":"2025-06-16 05:39:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":942026,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6539530/v1/2c1694bc-7842-4d37-b923-5efae5fa4dd5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe waterjet ablation (Aquabeam\u003csup\u003e®\u003c/sup\u003e) for treatment of symptomatic benign prostatichyperplasia: 3-years functional outcomes from a large Italian series (\u0026gt;200 cases)\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBenign prostatic hyperplasia (BPH) is a common condition in aging men, characterized by the non-cancerous enlargement of the prostate gland, which often leads to bladder outlet obstruction (BOO) and lower urinary tract symptoms (LUTS). These symptoms have a significant negative impact on quality of life, affecting sleep, daily activities, and overall well-being. Standard surgical treatment, such as Holmium-laser enucleation of prostate (HoLEP), is effective in reducing LUTS but lead to loss of ejaculatory function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, the Aquablation technique, based on waterjet ablation technology, emerged as a minimally invasive alternative for managing BOO caused by BPH. Aquablation uses high-pressure water to precisely ablate prostatic tissue, allowing for targeted removal with minimal damage to surrounding structures. This approach aims to offer relief from LUTS while preserving key aspects of sexual function, particularly ejaculation, which is a common concern for patients undergoing traditional BPH treatments [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the last years, Aquablation treatment was compared to the standard approaches (HoLEP and trans-urethral resection of prostate \u0026ndash; TURP), and the non-inferiority was demonstrated\u003c/p\u003e \u003cp\u003eAquablation proved to be a valid alternative to standard resection techniques [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and recently also to enucleation techniques [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], showing excellent long-term functional outcomes, good preservation of sexual function, a good safety profile, and good compliance for all prostate sizes and patient ages.\u003c/p\u003e \u003cp\u003e According to EAU guideline, Aquablation appeared non-inferior in terms of functional outcomes in patients with BOO caused by 30\u0026ndash;80 ml BPH (level of evidence: 1b) compared to TURP, and it was indicated as an alternative even if with a weak strength rate. Moreover, there are still concerns about management of bleeding [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Therefore, Aquablation remains under investigation, as the evidence levels described by Speakman et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] have not yet been reached. This study provides a comprehensive analysis of the three-year outcomes of Aquabeam\u0026reg; waterjet ablation in a cohort of patients treated for BPH-induced BOO. By evaluating changes in urinary symptoms, quality of life, and functional outcomes - including continence and ejaculatory function - this study seeks to assess the safety, efficacy, and durability of Aquablation over a medium-term follow-up period. Through these findings, we aimed to contribute valuable insights into the role of Aquablation in the evolving landscape of BPH management and to guide clinicians in making informed treatment decisions for patients with BPH.\u003c/p\u003e "},{"header":"Methods","content":"\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study was based on a retrospective analysis of 218 consecutive patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) with BOO due to BPH who were treated with Aquabeam\u0026reg; waterjet ablation between January 2019 and January 2022. All procedures were conducted across three high-volume referral centers specialized in BPH management. Patient data were obtained from a prospectively maintained database to ensure consistency and accuracy in data collection.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eMulti-centric, non-controlled, observational, retrospective based on prospectively maintained database study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion/exclusion criteria\u003c/h3\u003e\n\u003cp\u003ePatients included in the study were adult men diagnosed with symptomatic BPH, confirmed through clinical evaluation, imaging (axial and sagittal ultrasound imaging of prostate gland, multiparametric MRi of prostate if indicated in the definition of the PSA increase), and laboratory tests (urine test, urine culture, free and total PSA, renal function tests), complete 36-monthsd follow-up.\u003c/p\u003e \u003cp\u003e Criteria for inclusion were: presence of LUTS unresponsive to medical therapy, evidence of BOO based on clinical findings, patient's willingness to save ejaculation, complete follow-up, signed informed consent. Exclusion criteria included prior prostate surgery, prostate cancer diagnosis, severe medical comorbidities that would contraindicate the procedure, previous pelvic radiotherapy, previous systemic chemotherapy, known immune deficiency, active/uncontrolled urinary infections, liver, kidney, or hematologic function disorders, coexistence of tumors, and inability to participate.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eAll Aquabeam\u0026reg; waterjet ablation procedures were performed under general or spinal anesthesia, with patients positioned in lithotomy. The Aquabeam\u0026reg; device was used to deliver high-velocity waterjets, allowing precise and controlled ablation of the targeted prostatic tissue while sparing surrounding structures. This technique utilizes real-time imaging and robotic assistance to minimize the risks of damage to adjacent tissues. After the ablation, the \u0026ldquo;fluffy\u0026rdquo; tissue was removed by a loop, and subsequently the hemostasis was performed by bipolar energy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Operative time, catheterization duration, and length of hospital stay were recorded as part of procedural data.\u003c/p\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003eFunctional outcomes were evaluated pre-operatively and at multiple post-operative time points (3 months, 1 year, and annually up to 3 years post-surgery). The following measures were assessed: the IPSS (to quantify the severity of urinary symptoms, with scores categorized as mild, moderate, or severe); the maximum Urinary Flow Rate (Qmax) (measured using uroflowmetry to assess urinary flow dynamics; an increase in Qmax was considered indicative of improved urinary function); the Post-Void Residual (PVR) (measured via ultrasound to determine the amount of urine remaining in the bladder after voiding, with lower values suggesting improved bladder emptying); the Continence status (evaluated based on patient-reported continence levels and the need for any incontinence aids or medications); a specific focus on sexual function was given to rates of ejaculation preservation, an important consideration in BPH treatment.\u003c/p\u003e \u003cp\u003eComplications following the Aquabeam\u0026reg; waterjet ablation procedures were systematically documented and classified using the Clavien-Dindo classification system [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], a standardized grading system for surgical complications based on the level of intervention required for resolution. This classification facilitates objective and consistent reporting of post-operative complications across clinical studies. Grade 1 Complications were defined as any deviation from the normal post-operative course not requiring pharmacological treatment or surgical intervention. Grade 2 Complications require pharmacological treatment, such as antibiotics, analgesics, or anti-inflammatory drugs, without necessitating invasive procedures. Grade 3 Complications involve those requiring surgical, endoscopic, or radiological intervention.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe sample size and the relative statistical power of the study were not calculated due to the nature of the study. Descriptive statistics were employed to summarize patient demographics and baseline characteristics. Median values with interquartile ranges (IQR) were used for continuous variables, while categorical variables were expressed as percentages. Changes in outcome measures over time were assessed using paired statistical tests to compare pre-operative and post-operative values. Parametric and nonparametric variables were evaluated using ANOVA and Kruskal-Wallis, respectively. Statistical significance was defined as a two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. We conducted all analyses using statistical software STATA/SE version 18 (StataCorp, College Station, TX, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFollow-Up and Data Collection\u003c/h2\u003e \u003cp\u003ePatients were followed up at regular intervals, with the primary endpoint at 3 years post-surgery. Follow-up included physical examination, symptom assessment, and objective testing. Complications were documented and classified according to the Clavien-Dindo grading system, with attention to both short-term and long-term adverse effects.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eBaseline\u003c/h2\u003e\n\u003cp\u003eThe median age of patients was 61 years (IQR: 57\u0026ndash;66). Preoperative median PSA level was 2.52 ng/mL (IQR: 0.4\u0026ndash;21.6), reflecting a population with varied baseline prostate function. The median prostate volume measured via ultrasound was 55 mL (IQR: 40\u0026ndash;73) (table 1, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eOperative Data\u003c/h2\u003e\n\u003cp\u003eThe median operative time was 56 minutes (IQR: 20\u0026ndash;168) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e), the median catheterization time was 2 days (IQR: 1\u0026ndash;7), with the majority of patients achieving adequate voiding function shortly after removal. The length of hospital stay varied from 1 to 5 days, with a median stay of 2 days, indicating that most patients were discharged within 48 hours of the procedure (table 2).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003eFunctional Outcomes\u003c/h2\u003e\n\u003cp\u003eAt the 3-years follow-up, Aquabeam\u0026reg; demonstrated significant and durable improvements in key functional outcomes:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eUrinary Symptoms (IPSS): The median IPSS decreased from baseline, with patients reporting a median IPSS score of 5 (IQR: 3\u0026ndash;21). This marked improvement was evident as early as 3-months post-procedure and remained stable throughout follow-up, highlighting the efficacy of Aquabeam\u0026reg; in symptom management (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u0026nbsp;Qmax: Patients experienced an increase in urinary flow rate, with a median Qmax of 18 mL/s (IQR: 9\u0026ndash;26). This value represented a substantial improvement over baseline Qmax values, with gained in flow rate observed as early as three months post-operatively and sustained throughout follow-up (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eContinence and Ejaculatory Function: the continence rate remained at 100% at 3-years; the ejaculatory function was preserved in 87% of patients, with an increasing trend toward preservation over time (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e- Complications: 8.3% of patients (18 patients) experienced Grade 1 complications, including mild hematuria and dysuria, which were self-limiting and managed conservatively. Grade 2 complications were reported in 11.9% of patients (26 patients), most commonly urinary tract infections (UTIs) and symptomatic inflammation, both of which resolved with standard pharmacological treatment. Only 1 patient (0.5%) had a Grade 3 complication, which required temporary catheter re-insertion; this patient recovered fully, with no long-term complications reported. Eight patients (3.7%) experienced urinary retention and required the temporary catheter re-insertion (for a week) and all of them fully recovered without long-term complications. Importantly, all complications were temporary and resolved completely, supporting the safety profile of Aquabeam\u0026reg; in this patient population.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reinforced the growing body of literature that supports Aquabeam\u0026reg; waterjet ablation as a minimally invasive and effective treatment option for managing LUTS due to BPH. The study\u0026rsquo;s three-year follow-up data confirmed substantial improvements in functional outcomes and a favorable safety profile, underscoring Aquabeam\u0026reg; as a strong alternative to traditional treatments, which often pose greater risks, including ejaculatory and sexual dysfunction.\u003c/p\u003e \u003cp\u003eThe observed improvements in functional outcomes, including the reduction in IPSS and increases in Qmax, aligned with findings from major studies like WATER [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and WATER II [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], as well as data from the recent meta-analysis by Elterman and colleagues [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our cohort, the median IPSS at the 36-month follow-up was significantly reduced, with a median score of 5 (IQR: 3\u0026ndash;21), a result that resonates with the meta-analysis and WATER trial outcomes, which reported IPSS reductions of 15 to 17 points and sustained improvements at long-term follow-up [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn WATER II, after twelve months, significant improvements were seen in IPSS (mean decrease of 17 points), Qmax (increase of 12.5 cc/sec) and PVR (a drop of 171 cc in those with PVR\u0026thinsp;\u0026gt;\u0026thinsp;100 at baseline). At 5-years follow-up, 3% of patients required surgical retreatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], differently from our study were no patients needed to be retreated\u003c/p\u003e \u003cp\u003eIn the pivotal double-blind, multicenter RCT comparing Aquablation to transurethral resection of the prostate (TURP), IPSS reductions were similar between groups, with no significant difference in improvements in IPSS, Qmax, and post-void residual (PVR) after six months. Urodynamic studies of 66 patients enrolled in the WATER trial at six months follow-up showed significant changes in pdetQmax (reductions of 35 and 34 cm H20, respectively) and large improvements in BOO index in both groups [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The present study further supports these findings, with sustained IPSS and Qmax improvements over three years, indicating robust symptom relief in patients with a range of prostate sizes. Additionally, Aquablation maintained lower resection times (4 vs. 27 minutes for TURP), an advantage that may contribute to a quicker recovery and less tissue trauma.\u003c/p\u003e \u003cp\u003eOne of Aquabeam\u0026reg;\u0026rsquo;s most compelling benefits is its preservation of ejaculatory function, a critical factor for many patients when selecting a treatment for BPH. In our cohort, 87% of patients maintained ejaculation three years post-treatment, closely aligning with findings from the WATER [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and WATER II [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] trials, which reported ejaculatory preservation rates of 85% or higher. In contrast, TURP often has a high incidence of ejaculatory dysfunction, with the pivotal RCT noting rates of anejaculation at 36% for TURP versus 10% for Aquablation. This difference, further corroborated by the meta-analysis, highlights Aquabeam\u0026reg;\u0026rsquo;s advantage in minimizing sexual side effects. This outcome can be attributed to the precise tissue ablation technique of Aquablation, which minimizes neurovascular damage, preserving sexual function while providing effective LUTS relief.\u003c/p\u003e \u003cp\u003eThe safety profile of Aquabeam\u0026reg; observed in this study is consistent with findings from other studies, including the WATER trials and the meta-analysis. Most complications were minor (Clavien-Dindo Grades 1 and 2) and transient, with very few instances of Grade 3 complications, underscoring Aquabeam\u0026reg;\u0026rsquo;s minimally invasive nature. The WATER trial indicated a lower rate of persistent adverse events in the Aquablation group compared to TURP, further supporting its safety profile. Bleeding-related events were noted in WATER II, where 13.9% of patients required intervention, yet the overall transfusion rate was low. Results for the WATER trial have shown comparable hospital stay and catheterisation duration (1.4 and 1 day, respectively) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. One case of blood transfusion was reported after Aquabeam and none after TURP. In a systematic review of seven patient groups involving 446 patients treated by aquablation, although there was a significant haemoglobin drop (2.06 g/dL), it did not translate into increased transfusion rates. In WATER, fewer men in the Aquablation group had a persistent Clavien-Dindo grade 1 or 2 or higher adverse event compared to TURP (26% vs. 42%) at three months.\u003c/p\u003e \u003cp\u003eIn patients with a prostate volume between 80\u0026ndash;150 mL (WATER II trial), bleeding related events were observed in fourteen patients (13.9%) of which eight (7.9%) occurred prior to discharge and six (5.9%) occurred within one month of discharge. Blood transfusions were required in eight patients, return to the theatre for fulguration in three patients, and both transfusion and fulguration in two patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Maintenance of antegrade ejaculation was slightly lower in WATER II at 81% compared to 90% in the smaller prostates of WATER I [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In WATER II there was a 2% \u003cem\u003ede novo\u003c/em\u003e incontinence rate at twelve months [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn terms of procedural metrics, this study\u0026rsquo;s median operative time (56 minutes) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e5\u003c/span\u003e), catheterization duration, and hospital stay (2 days) were also in line with those observed in WATER and WATER II, where operative times were similarly brief, indicating the efficiency and minimally invasive nature of Aquabeam\u0026reg;. Furthermore, our study's transfusion rate was similarly low, aligning with data from a systematic review that demonstrated an acceptable hemoglobin drop (2.06 g/dL), with minimal impact on transfusion rates. Both this study and the meta-analysis suggest Aquablation\u0026rsquo;s durable improvements in IPSS and Qmax over three to five years. In WATER [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and WATER II [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] trials, IPSS improvements remained steady over five years, and Qmax improvements were 125% for Aquablation compared to 89% for TURP. While the surgical retreatment rate was slightly higher for Aquablation (5.1%) compared to TURP (1.5%), Aquablation still offers a compelling alternative, particularly for patients who prioritize ejaculatory function preservation. Notably, retreatment rates in larger prostates (WATER II cohort) were as low as 3% at five years, suggesting Aquablation\u0026rsquo;s potential efficacy in anatomically challenging cases.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn an analysis of procedural differences including data from WATER I and II, compared to a single pass of ablation, the use of two or more passes during Aquablation resulted in lower IPSS scores by four points, and lower IPSS QoL scores by 0.7 points at 24 and 36 months. Similarly, 36-month Qmax values were higher by 5 ml/sec in those with two or more passes than in those with one pass [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our experience, we generally performed a second or more treatment passes according the on-site modification of the prostate glad after the first treatment pass, in order to obtain a better ablation and therefore a higher improvement of functional outcomes; this was based even on Bach et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] study where independently from the prostate volume, a multiple treatment pass protocol led to improved voiding outcomes and IPSS improvement, without negative effect on ejaculatory function.\u003c/p\u003e \u003cp\u003eIn the initial findings of the multicentre Randomized-Controlled WATER III Trial, Aquablation was compared to HoLEP, and the therapy delivered similar symptom score reduction, superior ejaculatory function preservation, and superior continence preservation to laser enucleation in 80\u0026ndash;180 mL prostates. The WATER III represented a significant milestone with 3-month results demonstrating similar symptom relief while showing significantly lower rates of ejaculatory dysfunction (14.8% vs. 77.1%) and stress incontinence (0% vs. 9.1%) compared to laser enucleation, and with Aquablation procedural transfusion rate at 0% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Our data appeared comparable to this multicenter study, giving value to our findings.\u003c/p\u003e \u003cp\u003eOne of the issue of this technique is about the bleeding and the management of cautery after the ablation. In a study on the short-term functional outcomes and the efficacy of hemostasis performed with holmium laser after the prostatic hydroablation, D\u0026rsquo;Agostino et al. showed a low rate of complications for the combined approach for hemostasis and encouraged the functional results confirming the safety of this technique. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBusetto et al. reported that short-term treatment with dutasteride was able to reduce operative and perioperative bleeding in patients with large prostates (\u0026ge;\u0026thinsp;50 mL) undergoing bipolar TURP [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; otherwise, it is not yet clear whether 5α-Reductase inhibitors (5-ARIs) therapy can influence perioperative and functional outcomes after Aquablation. Furthermore, it is currently unclear whether chronic bacterial prostatitis and its different antibiotic / non-antibiotic treaTment can influence the outcome after ablation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]; these data are currently absent, but surely a sub-analysis of these data should be warranted for an increasingly personalized treatment of Aquablation.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThis study, while providing valuable insights into the medium-term efficacy and safety of Aquabeam\u0026reg; waterjet ablation for treating bladder outlet obstruction (BOO) in patients with benign prostatic hyperplasia (BPH), has several limitations that should be acknowledged.\u003c/p\u003e \u003cp\u003eFirstly, this was a retrospective analysis, which inherently introduces potential biases related to patient selection and data collection. Although data were prospectively maintained, the absence of randomization limits the ability to control for confounding factors that might affect outcomes, such as baseline patient characteristics or variations in technique across centers.\u003c/p\u003e \u003cp\u003eSecondly, the follow-up period was limited to a median of three years. While this timeframe allows for meaningful assessment of medium-term outcomes, it does not provide information on the long-term durability of Aquabeam\u0026reg; waterjet ablation. Consequently, further studies with extended follow-up periods are necessary to determine whether the functional improvements and high ejaculation preservation rates observed in this study are sustained over time.\u003c/p\u003e \u003cp\u003eAdditionally, this study did not include a control group of patients undergoing alternative treatments for BPH, such as transurethral resection of the prostate (TURP) or laser-based procedures, limiting direct comparisons. A comparative study design would help clarify the relative advantages and disadvantages of Aquabeam\u0026reg; waterjet ablation against established treatment options, particularly regarding outcomes like symptom relief, complication rates, and preservation of sexual function.\u003c/p\u003e \u003cp\u003eDespite the high preservation rate indicates that patients maintained relatively stable ejaculatory function following the Aquabeam\u0026reg; procedure, the specific quantitative MSHQ-EjD scores were not provided in the study summary. Further studies with detailed MSHQ-EjD scores could provide additional insights into the specific aspects of ejaculatory function preserved with Aquabeam\u0026reg; over a longer-term follow-up.\u003c/p\u003e \u003cp\u003eLastly, while the study reported low rates of complications and successful resolution of all adverse events, the sample size may still be insufficient to capture rarer but potentially significant complications or adverse effects. Larger multicenter studies or meta-analyses would provide a more comprehensive safety profile of the procedure.\u003c/p\u003e \u003cp\u003eIn summary, while the results of this study are promising, its retrospective nature, lack of long-term data, absence of a comparative group, and potential underrepresentation of rare complications indicate that further randomized, controlled studies with extended follow-up are warranted to fully establish the clinical value and durability of Aquabeam\u0026reg; waterjet ablation in the management of BPH.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings from this study indicate that Aquabeam\u0026reg; waterjet ablation is a safe and effective treatment for managing bladder outlet obstruction due to benign prostatic hyperplasia, with significant and sustained improvements in LUTS over a three-year period. Aquabeam\u0026reg; was associated with high rates of continence preservation and a notable ejaculation preservation rate of 87%, highlighting its potential as a preferred option for patients seeking relief from BPH symptoms with minimal impact on sexual function. The procedure also showed a low incidence of complications, which were generally mild and fully resolved without long-term sequelae.\u003c/p\u003e \u003cp\u003eThese results underscore Aquabeam\u0026reg; as an established, minimally invasive alternative to traditional surgical options of HoLEP in case of patients willing to preserve the ejaculatory function, providing relief from urinary symptoms while preserving quality of life. While the medium-term outcomes are encouraging, further studies with longer follow-up are essential to validate the durability of these benefits over time and to establish Aquabeam\u0026reg; as a standard treatment option for BPH as alternative to HoLEP.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthor Contributions: Conceptualization: P.A., D.L., D'A.D.; methodology: M.F., De.D.; validation: M.F., S.F.; formal analysis: M.F., S.F.; investigation: D.L.; resources: A.A., C.F.; data curation: D.L.; writing—original draft preparation: D.L., M.F.; writing—review and editing: D.D., B.G.M.; visualization: De.D., G.M., A.A., C.F.; supervision: P.A.. All authors have read, reviewed and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003eFunding: This research did not receive any funding to cover publication costs.\u003c/p\u003e\n\u003cp\u003eInstitutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the Humanitas Gavazzeni e Castelli for studies involving humans.\u003c/p\u003e\n\u003cp\u003eInformed Consent Statement: Written informed consent has been obtained from the patients to publish this paper.\u003c/p\u003e\n\u003cp\u003eData Availability Statement: The data presented in this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: None.\u003c/p\u003e\n\u003cp\u003eConflicts of Interest: The authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eManagement of Non-neurogenic Male LUTS EAU Guidelines. 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PMID: 30552937\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Aho T, Kramolowsky E, Thomas A, Kaufman RP Jr, Badlani G, Plante M, Desai M, Doumanian L, Te AE, Roehrborn CG (2022) Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol 29(1):10960\u0026ndash;10968\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePimentel MA, Yassaie O, Gilling P (2019) Urodynamic Outcomes After Aquablation. Urology 126:165\u0026ndash;170. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.urology.2019.01.020\u003c/span\u003e\u003cspan address=\"10.1016/j.urology.2019.01.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2019 Feb 2. PMID: 30721737\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesai M, Bidair M, Zorn KC, Trainer A, Arther A, Kramolowsky E, Doumanian L, Elterman D, Kaufman RP Jr, Lingeman J, Krambeck A, Eure G, Badlani G, Plante M, Uchio E, Gin G, Goldenberg L, Paterson R, So A, Humphreys M, Roehrborn C, Kaplan S, Motola J, Bhojani N (2019) Aquablation for benign prostatic hyperplasia in large prostates (80\u0026ndash;150 mL): 6-month results from the WATER II trial. BJU Int 124(2):321\u0026ndash;328. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/bju.14703\u003c/span\u003e\u003cspan address=\"10.1111/bju.14703\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen DD, Barber N, Bidair M, Gilling P, Anderson P, Zorn KC, Badlani G, Humphreys M, Kaplan S, Kaufman R, So A, Paterson R, Goldenberg L, Elterman D, Desai M, Lingeman J, Roehrborn C, Bhojani N (2020) Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30\u0026ndash;80 and 80\u0026ndash;150 mL prostates. 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Urology 169:167\u0026ndash;172. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.urology.2022.07.007\u003c/span\u003e\u003cspan address=\"10.1016/j.urology.2022.07.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Agostino D, Colicchia M, Corsi P, Romagnoli D, Del Rosso A, Modonutti D, Busetto GM, Ferro M, Schiavina R, Molinaroli E, Artibani W, Porreca A (2021) The combination of waterjet ablation (Aquabeam\u0026reg;) and holmium laser power for treatment of symptomatic benign prostatic hyperplasia: early functional results. Cent Eur J Urol 74(2):222\u0026ndash;228. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5173/ceju.2021.0049\u003c/span\u003e\u003cspan address=\"10.5173/ceju.2021.0049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBusetto GM, Giovannone R, Antonini G, Rossi A, Del Giudice F, Tricarico S, Ragonesi G, Gentile V, De Berardinis E (2015) Short-term pretreatment with a dual 5α-reductase inhibitor before bipolar transurethral resection of the prostate (B-TURP): evaluation of prostate vascularity and decreased surgical blood loss in large prostates. BJU Int 116(1):117\u0026ndash;123. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/bju.12917\u003c/span\u003e\u003cspan address=\"10.1111/bju.12917\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2015 Jan 21. PMID: 25291499\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBusetto GM, Giovannone R, Ferro M, Tricarico S, Del Giudice F, Matei DV, De Cobelli O, Gentile V, De Berardinis E (2014) Chronic bacterial prostatitis: efficacy of short-lasting antibiotic therapy with prulifloxacin (Unidrox\u0026reg;) in association with saw palmetto extract, lactobacillus sporogens and arbutin (Lactorepens\u0026reg;). BMC Urol 14:53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2490-14-53\u003c/span\u003e\u003cspan address=\"10.1186/1471-2490-14-53\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 25038794; PMCID: PMC4108969\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Baseli\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"599\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003eMEDIAN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003eRANGE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e57-66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e44-80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePRE-OP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eprostate volume, ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e40-73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e22-200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003epresence of middle lobe, yes/no (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e92/126 (42,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eQmax, ml/s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e6,2-11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e2-17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003etPSA, ng/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2,52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,4-21,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e1,59-4,27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003ePost-void residual, ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e72,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0-420\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003epresence of bladder lithiasis, yes/no (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4/218 (1,8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eIPSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e15-23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eQoL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e4-5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eIndwelling bladder catheter, yes/no (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1/218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eUrinary incontinence, yes/no\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7/211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003estress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eurge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003ePad, yes/no (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2/216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eHemoglobin, g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e15,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e10,7-17,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e14,4-15,7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003emedications, yes/no\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e201/17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003ealfa-blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e5-ARI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003ecombined\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;ne characteristics\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Peri-o\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"525\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSURGERY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003eMEDIAN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eOperation time (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e20-168\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003ehystology, yes/no (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eperformed/not performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e46/172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003enegative for cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e45/46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003epT1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1/46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u003cu\u003eearly, yes/no (%)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7/211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003ebleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eblood tranfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003erectal injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u003cu\u003elate, yes/no (%)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e3/215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003ebladder neck sclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eurethral stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOST-OP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eHemoglobin, g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9,2-17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eTime of catheterization, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1-7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eTime of hospitalization, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 325px;\"\u003e\n \u003cp\u003eurinary incontinence at discharge, yes/no (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0/218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eperative data\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Aquablation, waterjet ablation, benign prostatic hyperplasia, LUTS, bladder outlet obstruction, ejaculatory preservation, medium-term outcomes, Aquabeam","lastPublishedDoi":"10.21203/rs.3.rs-6539530/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6539530/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003cbr\u003e\n\u003c/strong\u003eLower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) significantly affect the quality of life in men. Traditional surgical treatments offer symptom relief but may contribute to sexual dysfunction. Waterjet ablation, or Aquablation, is a minimally invasive technique, alternative to standard Holmium-laser enucleation of prostate (HoLEP), that uses high-pressure water to ablate prostatic tissue, offering both functional and sexual advantages.\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the three-year functional outcomes of Aquabeam® waterjet ablation for the treatment of bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH). We focused on measuring changes in urinary symptoms, quality of life, continence, and ejaculatory function, along with the incidence of complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nWe conducted a retrospective analysis from a prospectively maintained database of 218 consecutive BPH patients treated with Aquabeam® waterjet ablation. The procedures were performed between January 2019 and January 2022 across three referral centers for BPH management. Functional outcomes were evaluated pre- and post-operatively and included International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), post-void residual urine (PVR), continence status, sexual function, and ejaculatory function. The median follow-up was 3 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nThe median age of patients at surgery was 61 years (IQR: 57–66), with median PSA levels of 2.52 ng/mL (IQR: 0.4–21.6) and a median prostate volume of 55 mL (IQR: 40–73). The median operative time was 56 minutes (IQR: 20–168), with a median catheterization time of 48 hours (IQR: 24–480) and a hospital stay of 48 hours (IQR: 24–600).\u003c/p\u003e\n\u003cp\u003eAt 3-year follow-up, patients experienced significant symptom relief, with a median IPSS score of 5 (IQR: 3–21) and a Qmax of 18 mL/s (IQR: 9–26). These results were significantly better than baseline scores, observed as early as three months post-procedure, and remained stable throughout the follow-up period.\u003c/p\u003e\n\u003cp\u003eThe continence rate was 100%, and the ejaculation preservation rate was 87%, with a positive trend over time.\u003c/p\u003e\n\u003cp\u003eComplications were classified according to the Clavien-Dindo system: 8.3% of patients experienced Grade 1 complications (18 patients), 11.9% had Grade 2 (26 patients), and only 0.5% encountered Grade 3 complications. All complications were temporary and resolved completely without any long-term effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nThe Aquabeam® waterjet ablation procedure was safe, effective, and reproducible, offering clinically meaningful improvement in LUTS and quality of life for BPH patients. Its ability to preserve ejaculation in a high percentage of patients underscores its advantage over traditional methods. These medium-term outcomes are promising, although further research into long-term durability is necessary to confirm the sustained benefits of the procedure.\u003c/p\u003e","manuscriptTitle":"The waterjet ablation (Aquabeam®) for treatment of symptomatic benign prostatichyperplasia: 3-years functional outcomes from a large Italian series (\u0026gt;200 cases)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 16:31:18","doi":"10.21203/rs.3.rs-6539530/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9589820-b5d2-4a8f-a317-5a20f5a05af6","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-08T21:23:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 16:31:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6539530","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6539530","identity":"rs-6539530","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}