Can Aquablation treatment help to effectively reduce the long waiting list of patients with surgical indication for benign prostatic obstruction in a fully public healthcare system? Results of the first 100 cases from a single-center same-operator cohort

Can Aquablation treatment help to effectively reduce the long waiting list of patients with surgical indication for benign prostatic obstruction in a fully public healthcare system? 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Results of the first 100 cases from a single-center same-operator cohort Davide Perri, Giovannalberto Pini, Serena Maruccia, Massimo Menozzi, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8756172/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose To assess the efficacy and safety of Aquablation treatment in a single-center same-operator cohort and its potential role in reducing the long waiting list of patients with surgical indication for benign prostatic obstruction (BPO). Materials and methods Patients with surgical indication for BPO underwent Aquablation. All patients were treated by the same operator (D.P.) in a single center (Sant’Anna hospital, Como, Italy). Ablation was performed according to the standardized technique and coagulation through bipolar resectoscope was done in all cases. Perioperative parameters, functional outcomes and complications were assessed. Results 100 consecutive patients were included. Mean prostate size was 90.9 ml (min 40 ml, max 300 ml). Mean total operative time was 38.7 min, with a mean ablation time of 14.3 min and coagulation time of 21.8 min. No intraoperative complications were reported. In 2 cases a technical problem occurred and solved by replacing the handpiece. Postoperatively, 3 patients (3.0%) underwent urinary retention without haematuria, 2 patients (2.0%) underwent clots-induced retention, 1 patient (1.0%) developed an infection. No urethral strictures, nor bladder neck sclerosis were diagnosed during the follow-up, as well as no cases of stress urinary incontinence. Functional outcomes significantly improved compared to the preoperative evaluation. Conclusions Aquablation proved to be not only a fast treatment when performed by the same hands, but also a reliable option in terms of efficacy and safety, with good functional outcomes and very low complication rates. The shorter operative time provided by this technique may help to reduce the long waiting list of BPO patients with surgical indication. Aquablation AquaBeam Benign prostatic obstruction Benign prostatic hyperplasia Introduction Benign prostatic obstruction (BPO) is the most common cause of lower urinary tract symptoms (LUTS) and represents a frequent condition affecting older men. Disease prevalence has been shown to increase with advancing age. Autopsy studies have shown BPO prevalence to be as high as 60% for men in their 60s and more than 80% in men over 70 years [ 1 ]. Definitions should be carefully assessed. Benign prostatic hyperplasia (BPH) is a histological definition, BPO refers to a condition with blockage to urinary flow [ 2 ]. With the increase of BPH prevalence, the rate of BPO and symptomatic patients with LUTS increases as well. Despite some differences in reported epidemiologic data across populations, overall prevalence has raised worldwide thought the last decades and is still increasing, due mainly to aging population [ 3 ]. According to the Global Burden of Diseases, Injuries and Risk Factors Study, from 1990 to 2021 there was a 122% increase in prevalence. Over the past 30 years, the burden of BPH in low socio-demographic index (SDI) regions have shown an upward trend. High-SDI regions exhibit a stable burden, suggesting limitations in effective treatment options [ 4 ]. In addition, Western populations have significantly higher prostate volumes than those from other parts of the world, particularly Southeast Asia [ 5 ]. The raising prevalence of BPO in the aging population contributes to increasing the waiting list for patients with surgical indication. Clinical implications of long-term BPO are well known and complications may develop though time in terms of urinary tract infections (UTI), bladder stones, chronic and acute urinary retention (AUR), bladder diverticula, irritative symptoms, detrusor over- or underactivity. Quality of life of patients is overall impaired [ 6 ]. The time from diagnosis to treatment can affect surgical outcomes, therefore efforts should be done in order to reduce it. New minimally invasive surgical treatments (MISTs) have been developed in recent years. Among others, shorter operative time is a common described advantage. Patients selection is crucial and many factors should be considered, including prostate volume, presence of third lobe, bladder neck sclerosis, concomitant urethral stricture, comorbidities and the overall obstruction status [ 7 ]. Aquablation (AquaBeam® Robotic System, Procept BioRobotics, Redwood City, CA, USA) has emerged as a reliable alternative to standard techniques, namely transurethral resection of the prostate (TURP) and endoscopic enucleation of the prostate (EEP). Speed of treatment is a known advantage, as typical of MISTs. However, Aquablation seems to cover a wider range of patients with surgical indication for BPO compared to other MISTs. In the present study we evaluated the outcomes of the first 100 patients treated by the same operator to assess the potential role of Aquablation as a safe and effective treatment to reduce the long waiting list of BPO patients in our public hospital. Materials and methods Patients suffering from LUTS due to BPH with surgical indication were considered. Prostate volume < 40 ml, coagulation impairments, non-suspendable anticoagulant therapy, neurogenic bladder were exclusion criteria. Patients with bladder stones, bladder diverticula without indication to diverticulectomy, prostate cancer, third lobe, indwelling catheter, concomitant bladder neck sclerosis or urethral stricure were included. Preoperatively, digital rectal examination, prostate specific antigen (PSA), prostate volume, haemoglobin (Hb) value, uroflowmetry with maximum flow rate (Qmax) measurement, post-void residual (PVR), International prostate symptoms score (IPSS) and Quality of Life (QoL) score were assessed. All patients had negative urine culture. In case of positive urine culture, antibiotic therapy was given to reach negativization. In cases with persistent positive urine culture, targeted antibiotic therapy was started 5 days before surgery. Aquablation was performed using the specific device, including the single-use handpiece and the dedicated transrectal ultrasound probe. The standardized technique was followed for every case. In case of concomitant urethral stricture, a cold-knife urethrotomy was performed at the beginning of the procedure. Bladder stones were treated before prostate ablation as well. Treatment planning was carried out under ultrasound guidance. After the ablation phase, a bipolar resectoscope was used to perform coagulation and to remove the residual parts of adenoma. A 3-way 22 Ch catheter was left in place at the end of the procedure with continuous irrigation. All procedures were performed in a single center (Sant’Anna hospital, Como, Italy) by the same surgeon (D.P.), with a high expertise in both TURP and prostate laser enucleation. The choice of treatment between Aquablation and EEP was based on patients’ preference after adequate counseling, independently from the will to preserve ejaculation. Patients strongly motivated to preserve anterograde ejaculation were given indication to Aquablation. Intraoperative and postoperative data were collected. Total operative time was divided into ablation time (defined as the time from the beginning of the procedure to the removal of Aquablation handpiece) and resection/coagulation time (defined as the time from insertion of the resectoscope to the placement of the catheter, including the resection of residual parts of adenoma and coagulation). Functional outcomes after six months were assessed through IPSS score, Qmax, PVR and QoL score. Stress urinary incontinence was recorded as well as postoperative complications. Mean and standard deviation (SD) vs. numbers and proportions were used to describe continuous and categorical variables, respectively. Student’s t-test was used to test continuous variables conforming to a normal distribution. Data were analyzed with R software version 3.4.1 (R Foundation for Statistical Computing, Vienna, Austria). Results Overall, 100 consecutive patients were treated. Preoperative features are summarized in Table 1 . Mean prostate volume was 90.9 ml (min 40 ml, max 300 ml). Preoperatively, patients had mean IPSS score 20.3, mean Qmax 8.3 ml/s, mean PVR 105.3 ml and mean QoL score 5.3. At preoperative blood test, mean haemoglobin (Hb) value was 13.7 g/dl. Among the treated patients, 39 (39.0%) had a third lobe, 24 (24.0%) had an indwelling catheter at the time of surgery and 6 (6.0%) had a bilateral hydronephrosis due to the lower urinary tract obstruction. 15 patients (15.0%) had one or more bladder stones, whereas in 2 cases (2.0%) a urethral stricture was incidentally found at the level of the bulbar urethra. In both cases a BPO was contextually present. At the time of surgery 71 patients (71.0%) were taking alpha-blockers, 43 (43.0%) were taking 5-alpha-reductase inhibitors and 23 (23.0%) were under combination therapy. Oral anticoagulation therapy was stopped and bridged to low-molecular-weight heparin (LMWH) in 5 patients (5.0%), whereas Clopidogrel was stopped without bridging in 3 cases. All patients assuming Acetylsalicylic acid didn’t stop the therapy before or after the surgery. Metastatic prostate cancer had been detected in one patient. Among the whole cohort only 16 patients (16.0%) were strongly interested in preserving anterograde ejaculation (Table 1 ). Mean total operative time was 38.7 min. Specifically, mean ablation time was 14.3 min and mean resection/coagulation time 21.8 min. In the 2 cases with incidental finding of a bulbar urethral stricture, a cold-knife urethrotomy was performed to allow the insertion of the Aquablation handpiece. These two patients had a prostate volume of 100 ml and 90 ml, with a bulky third lobe. Therefore, the Aquablation treatment was performed as in both cases a BPO condition was present beside the stricture. Among the 15 patients (15.0%) with bladder stones, 11 underwent a Holmium:YAG laser cystolithotripsy, whereas 4 underwent open cystolithotomy before prostate ablation. No intraoperative complications occurred, but in 2 cases (2.0%) a technical problem was reported and solved through the replacement of the handpiece with a new one (Table 2 ). Mean length of stay was 2.1 days, whereas mean catheterization time was 3.6 days. Mean Hb drop at first postoperative day (POD) was 1.5 g/dl. Six months after surgery mean IPSS score was 5.4, mean Qmax 18.6 ml/s, mean PVR 15.9 ml and mean QoL score 1.4. Only 1 patient (1.0%) needed a secondary treatment because of a residual portion of the third lobe causing LUTS, which was removed through an endoscopic bipolar resection. Among the 16 patients strongly interested in preserving anterograde ejaculation, all of them were satisfied from the treatment (Table 2 ). Urinary tract infection (UTI), defined as the presence of fever not otherwise justified, occurred in 1 case (1.0%) and required a prolonged hospitalization for a proper antibiotic therapy. 3 patients (3.0%) underwent acute urinary retention (AUR) without haematuria, whereas 2 patients (2.0%) underwent clots-induced retention. In all these cases a bladder catheter was placed and successfully removed 7 days afterwards. No patients required blood transfusions. Stress urinary incontinence, bladder neck sclerosis and urethral strictures were never reported during the follow-up (Table 2 ). Discussion Aquablation consists on a robot-assisted endoscopic ablation of prostatic adenoma through a high-pressure heat-free saline waterjet. Treatment is planned with a specific software that allows a precise ultrasound contouring of the adenoma and it is performed under real-time monitoring by simultaneous cystoscopy and transrectal ultrasound [ 8 ]. Multiple studies have already shown the efficacy of Aquablation in improving urinary symptoms, with significant improvements in IPSS score, QoL score, Qmax and PVR at urofluometry [ 9 ]. Outcomes were comparable to TURP [ 10 ] even when dealing with big prostate volumes [ 11 ]. The comparative study by Justo Quintas et al. demonstrated that both Aquablation and Holium:YAG laser enucleation of the prostate (HoLEP) significantly improved micturition at six months, with no statistically significant differences in functional outcomes. Aquablation had a notably lower rate of ejaculatory dysfunction (6.6% vs. 89.3%, p < 0.001), which may offer a considerable quality-of-life advantage for certain patients. While HoLEP achieved greater reductions in prostate volume and PSA levels, Aquablation had a shorter tissue removal time and required less surgical expertise. Postoperative hemoglobin drop was higher with Aquablation, but transfusion rates remained low and comparable between both groups [ 8 ]. Despite the available evidence on functional outcomes and the know advantages in terms of short learning curve [ 12 ], compared to the steeper one of laser enucleation [ 13 , 14 ], Aquablation’s spread is still limited. Concerns don’t lie only on the economic burden, which anyway depends on the costs and refunds in each country, but also on the urologists’ fear of leaving adenomatous tissue on the prostatic capsule and of perioperative bleeding. However, the fear of bleeding seems to be related to data from the very first experiences of Aquablation treatments, before the adoption of the haemostatic protocol [ 15 ]. Therefore, most surgeons don’t perceive many advantages in this technique, especially if they are already able in doing prostate enucleation. The aim of our study was to show a new perspective in which to find an additional benefit from the Aquablation treatment. In many countries, like in our public healthcare system, the waiting list of BPO patients with surgical indication is long, up to some years. Many factors concur to this issue, including the aging male population and few healthcare resources. Despite its benignity, prolonged BPO can severely affect bladder function and consequently surgical outcomes. In this scenario, given the already demonstrated functional outcomes and low complication rates, the significantly shorter operative time of Aquablation may contribute to solve this often underestimated problem. Functional outcomes were significantly improved when comparing postoperative data to preoperative values. Specifically, IPSS score showed a mean reduction of 14.9 points, Qmax a mean increase of 10.3 ml/s, PVR a mean decrease of 89.4 ml and QoL score a mean decrease of 3.9 points. These outcomes were not only comparable to those of previously published cohorts of Aquablation patients [ 16 ], but also to those of patients treated with endoscopic laser enucleation performed by the same operator irrespective of the type of laser used [ 17 , 18 ]. Only one patient had to be retreated six months after the procedure because of am obstructive residual part of the third lobe. No patients required alpha-blockers or 5-ARIs postoperatively. Regarding sexual function, all patients who declared to be strongly interested in preserving anterograde ejaculation, were satisfied from the result of the treatment. The success rate was therefore 100%, higher compared to other reports from literature [ 19 ]. However, some aspects should be considered. Firstly, the number of patients interested in ejaculation was relatively low and only in these cases the apical paracollicular tissue preserved by the Aquablation machine was left in place. In all the other patients, the preservation of this tissue was minimized during the planning and the residual apical tissue was removed with the resectoscope to achieve a more complete treatment. Secondly, the rate of preservation of ejaculatory function should be evaluated considering only the interested patients, as this aspect influences the treatment planning by the surgeon. This may explain the higher success rate compared to other studies. Thirdly, in a previous publication we underlined the importance of patients’ satisfaction beyond the simple persistence of seminal fluid at the time of ejaculation. Specifically, we showed that satisfaction rate was nearly 70% compared to an anterograde ejaculation rate of nearly 80% in a cohort of patients treated with ejaculation-sparing Thulium:YAG laser enucleation. Neverthless, both rates were higher among Aquablation patients [ 20 ]. No patients reported significant changes in erectile function (Table 2 ). Mean total operative time was quite short, accounting for 38.7 min. This data is in line with other reports [ 21 ] and not surprising in itself. However, some considerations are due. Firstly, total operative time comprises the time needed to remove residual parts of adenoma to complete the treatment and the time needed to reach a proper haemostasis. This specific time that we called “resection/coagulation time” accounts for only 21.8 min, which means that the ablation phase managed to remove the majority of adenomatous tissue and that haemostatic control was easily reached. In our perspective this aspect should encourage urologists to move beyond the fear of bleeding. Secondly, the short operative time should be evaluated in light of the quite high mean prostate volume. If we consider the distribution within the cohort, median prostate volume was 80 ml with an interquartile range 70–100 ml (Table 1 ). Indeed, prostates up to 300 ml were treated. In our opinion our experience shows that even large and very large prostates can be effectively treated with Aquablation with a short operative time. This brings to one of the key messages of the study, showing that Aquablation may play an important role in reducing the long waiting list of BPO patients by allowing a fast and effective treatment for a very wide range of prostate volumes. Thirdly, it is of note that this was our first experience with the technique. The operator had high experience with TURP and laser enucleation, but had never performed Aquablation procedures before. Given the low operative time, good functional outcomes and low complication rate, we can affirm that the learning curve of the procedure is short. Moreover, the strict standardization of the treatment makes it very easily reproducible. Lastly, the operative time was notably inferior to that of laser enucleation when considering prostates of any volume [ 22 , 23 ]. Similar differences were found with patients treated with laser enucleation by the same operator [ 17 ] (Table 2 ). Notably, our cohort included patients with concomitant bladder stones or urethral stricture. In those cases urethrotomy, cystolithotomy or cystolithotripsy was performed before the Aquablation. This aspect underlines once more the high versatility of Aquablation procedure. Other MISTs have some limitations in inclusion criteria, starting from prostate volume and the presence of a third lobe. Most of them can be performed as outpatient procedures with mild sedation, but the presence of concomitant conditions like bladder stones imposes to switch to a deeper anesthesia and to perform the treatment in the operating room. This is not a problem with Aquablation, which must be performed under general or spinal anesthesia. To conclude, Aquablation is feasible in a very wide range of patients, not only in terms of prostate volume. Complication rate was overall very low, with only 6 patients experiencing Clavien-Dindo grade II events. Interestingly, 5 patients underwent urinary retention after catheter removal. However, 3 of them had no haematuria and clots. In these cases the retention was likely due to bladder neck oedema or residual fluffy tissue from the waterjet ablation. On the contrary, 2 patients had clots-induced retention, which reinforces the concept of Aquablation as a safe treatment in terms of bleeding risk. Stress incontinence is a know problem after HoLEP, even though usually transient. Rates described in literature are different, with studies reporting up to 20% of incontinence 1 month after surgery and 10% after 3 months [ 24 ]. Despite many factors have been associated to postoperative incontinence [ 25 ], the mechanical distress on the sphincter due to the technical aspect of enucleation plays an important role [ 26 ]. This may explain the absence of stress incontinence within our cohort (Table 2 ). Mean length of stay was comparable to previous reports on patients who underwent laser enucleation [ 17 , 18 ]. On the contrary, catheterization time seems slightly longer. In all cases the continuous irrigation was stopped the morning after the procedure and the decision to remove the catheter was taken upon the colour of urine starting from the day thereafter. Among Aquablation patients we found a higher tendency in having reddish urine during the first days after the procedure and this explains why they kept the catheter for a slightly longer time. This is in line also with the higher Hb drop at first POD, compared to patients undergoing laser enucleation [ 17 ]. Despite this, neither blood transfusions nor surgical haemostasis were needed. This further underlines the proven safety of Aquablation in terms of bleeding risk and once again should help surgeons to overcome old fears. Some limitations of the study need to be acknowledged. Firstly, the relatively low number of patients is a main concern. Secondly, there was no comparison with other treatments. However, the main aim of the study was to show the advantages of Aquablation from another interesting perspective, and not to add more comparative data to the ones already available. Thirdly, a cost analysis was not performed. However, this kind of analysis may be very complex, as it depends on the costs and refunds in each specific country and also within the same country. Cost effectiveness was beyond the purposes of our study. Fourthly, only one operator was involved. Mean operative time relates to surgeon’s proficiency and different operators may have different outcomes. Lastly, functional outcomes were evaluated six months after surgery. Very-long-term results are still lacking and will be the object of future studies. Conclusion Aquablation has an established reliability as an alternative to standard techniques for BPO, also in patients not interested in preserving anterograde ejaculation. Micturition improvements are comparable to those of prostate laser enucleation and the rate of complications is very low, overtaking the old fear of bleeding. Mean total operative time is short, even taking into account the time needed to remove residual parts of the adenoma and to reach a proper haemostasis. Therefore, Aquablation may play a role in reducing the long waiting list of BPO patients with surgical indication within our public healthcare system. Declarations Authors’ Contribution Perri D.: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing Pini G.: Supervision Maruccia S.: Data analysis Menozzi M.: Data collection or management Rivolta L.: Data collection or management Romero-Otero J.: Protocol/project development, Supervision Somani B.: Supervision Herrmann T.: Supervision Demirkiran E.D.: Data collection or management Besana U.: Supervision Sangalli M.N.: Supervision Pastore A.L.: Protocol/project development, Superivision Andreev R.: Data collection or management Govorov A.: Supervision Bozzini G.: Protocol/project development, Supervision Funding and/or Conflicts of interests/Competing interests The authors did not receive support from any organization for the submitted work All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. 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Transl Androl Urol 13:1775–1785. https://doi.org/10.21037/tau-24-71 Agreda-Castañeda F, Freixa-Sala R, Franco M et al (2024) Predictive factors of post-HoLEP incontinence: differences between stress and urgency urinary incontinence. World J Urol 42:281. https://doi.org/10.1007/s00345-024-04984-5 Harraz AM, Aldousari S, Eltafahny AI et al (2025) Laser-Driven Dissection Achieves Earlier Continence Recovery Than Blunt Dissection During Holmium Laser Enucleation of the Prostate. Low Urin Tract Symptoms 17:e70006. https://doi.org/10.1111/luts.70006 Tables Table 1 Descriptive characteristics of 100 patients with lower urinary tract symptoms who underwent Aquablation Aquablation (n = 100) Age, years Mean (SD) 68.7 (7.4) Prostate volume, ml Mean (SD) Min-Max Median (IQR) 90.9 (19.3) 40–300 80 (70–100) IPSS score Mean (SD) 20.3 (5.4) Qmax, ml/s Mean (SD) 8.3 (2.1) PVR, ml Mean (SD) 105.3 (24.0) QoL score Mean (SD) 5.3 (0.6) PSA, ng/ml Mean (SD) 4.4 (1.8) Hb, g/dl Mean (SD) 13.7 (2.8) Third lobe n (%) 39 (39.0) Indwelling catheter n (%) 24 (24.0) Bladder stones n (%) 15 (15.0) Urethral stricture n (%) 2 (2.0) Hydronephrosis n (%) 6 (6.0) Alpha-blockers assumption n (%) 71 (71.0) 5-ARIs assumption n (%) 43 (43.0) Combination therapy n (%) 23 (23.0) Prostate cancer n (%) 1 (1.0) Anticoagulant therapy n (%) 5 (5.0) Antiplatelet therapy • Acetylsalicylic acid • Clopidogrel n (%) 17 (17.0) 14 (14.0) 3 (3.0) Interest in ejaculation n (%) 16 (16.0) SD = Standard Deviation, IQR = Interquartile range, IPSS = International Prostatic Symptoms Score, Qmax = Maximum flow rate, PVR = Post-Void Residual, QoL = Quality of Life, PSA = Prostate-Specific Antigen, Hb = Haemoglobin, 5-ARIs = 5-alpha reductase inhibitors Table 2 Intraoperative and postoperative outcomes of 100 patients with lower urinary tract symptoms who underwent Aquablation Aquablation (n = 100) Operative time, min Mean (SD) 38.7 (8.5) Ablation time, min Mean (SD) 14.3 (2.1) Resection/Coagulation time, min Mean (SD) 21.8 (6.6) Urethrotomy n (%) 2 (2.0) Cystolithotripsy n (%) 11 (11.0) Cystolithotomy n (%) 4 (4.0) Technical problems n (%) 2 (2.0) Length of stay, days Mean (SD) 2.1 (0.5) Catheterization time, days Mean (SD) 3.6 (1.3) Hb drop at 1st POD, g/dl Mean (SD) 1.5 (0.6) 6-month IPSS score Mean (SD) 5.4 (2.4) 6-month Qmax, ml/s Mean (SD) 18.6 (2.8) 6-month PVR, ml Mean (SD) 15.9 (13.6) 6-month QoL score Mean (SD) 1.4 (0.3) Anterograde ejaculation n (%) 16 (100) Secondary treatment n (%) 1 (1.0) UTI n (%) 1 (1.0) AUR n (%) 3 (3.0) Clots retention n (%) 2 (2.0) Blood transfusions n (%) 0 (0) Stress incontinence n (%) 0 (0) SD = Standard Deviation, Hb = Haemoglobin, POD = Post-Operative Day, IPSS = International Prostatic Symptoms Score, Qmax = Maximum flow rate, PVR = Post-Void Residual, QoL = Quality of Life, UTI = Urinary Tract Infection, AUR = Acute Urinary Retention Additional Declarations No competing interests reported. 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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-8756172","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588270290,"identity":"786e332d-d125-45d7-878e-587a567f9fff","order_by":0,"name":"Davide 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Lariana","correspondingAuthor":false,"prefix":"","firstName":"Lorenzo","middleName":"","lastName":"Rivolta","suffix":""},{"id":588270295,"identity":"60553d24-122d-4554-af52-ea4e5b9befbc","order_by":5,"name":"Javier Romero-Otero","email":"","orcid":"","institution":"ROC Clinic and HM Hospitales","correspondingAuthor":false,"prefix":"","firstName":"Javier","middleName":"","lastName":"Romero-Otero","suffix":""},{"id":588270297,"identity":"bb9bbd0f-be4a-40b4-83aa-102f9d7d5616","order_by":6,"name":"Bhaskar Somani","email":"","orcid":"","institution":"University Hospital Southampton, NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Bhaskar","middleName":"","lastName":"Somani","suffix":""},{"id":588270298,"identity":"7d73052d-703e-4caf-87e0-61f55584bd18","order_by":7,"name":"Thomas Herrmann","email":"","orcid":"","institution":"Kantonspital Frauenfeld, Spital Thurgau AG","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Herrmann","suffix":""},{"id":588270299,"identity":"5e1e2cb0-4f4e-45e8-86d3-dd80fa68d4b5","order_by":8,"name":"Engin Denizhan Demirkiran","email":"","orcid":"","institution":"Zonguldak Bülent Ecevit University","correspondingAuthor":false,"prefix":"","firstName":"Engin","middleName":"Denizhan","lastName":"Demirkiran","suffix":""},{"id":588270300,"identity":"4c918120-21f6-4b3e-95fb-44e64b9f33ef","order_by":9,"name":"Umberto Besana","email":"","orcid":"","institution":"Azienda Socio Sanitaria Territoriale Lariana","correspondingAuthor":false,"prefix":"","firstName":"Umberto","middleName":"","lastName":"Besana","suffix":""},{"id":588270301,"identity":"90c51298-0c39-4d5a-bd20-7dd2ed35d1c1","order_by":10,"name":"Mattia Nicola Sangalli","email":"","orcid":"","institution":"Azienda Socio Sanitaria Territoriale Lariana","correspondingAuthor":false,"prefix":"","firstName":"Mattia","middleName":"Nicola","lastName":"Sangalli","suffix":""},{"id":588270302,"identity":"372e8cf3-9d59-4687-b1f9-9bf02c851164","order_by":11,"name":"Antonio Luigi Pastore","email":"","orcid":"","institution":"Sapienza University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"Luigi","lastName":"Pastore","suffix":""},{"id":588270303,"identity":"52e49ab4-3053-41cc-bba2-68bbc6cbba6a","order_by":12,"name":"Roman Andreev","email":"","orcid":"","institution":"Moscow State University of Medicine and Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Roman","middleName":"","lastName":"Andreev","suffix":""},{"id":588270304,"identity":"7e6cc745-0991-492f-866f-5823cd0d8ae8","order_by":13,"name":"Alexander Govorov","email":"","orcid":"","institution":"Moscow State University of Medicine and Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Govorov","suffix":""},{"id":588270305,"identity":"ee6816ed-1604-4059-ac45-6180ac003524","order_by":14,"name":"Giorgio Bozzini","email":"","orcid":"","institution":"Azienda Socio Sanitaria Territoriale Lariana","correspondingAuthor":false,"prefix":"","firstName":"Giorgio","middleName":"","lastName":"Bozzini","suffix":""}],"badges":[],"createdAt":"2026-02-01 12:39:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8756172/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8756172/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102446338,"identity":"6a41fd94-7016-45d2-b9e7-0ea822391d23","added_by":"auto","created_at":"2026-02-11 17:40:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":619122,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8756172/v1/f4b5a507-4b5c-4221-bcc6-e7f6938b6e9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Can Aquablation treatment help to effectively reduce the long waiting list of patients with surgical indication for benign prostatic obstruction in a fully public healthcare system? Results of the first 100 cases from a single-center same-operator cohort","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBenign prostatic obstruction (BPO) is the most common cause of lower urinary tract symptoms (LUTS) and represents a frequent condition affecting older men. Disease prevalence has been shown to increase with advancing age. Autopsy studies have shown BPO prevalence to be as high as 60% for men in their 60s and more than 80% in men over 70 years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Definitions should be carefully assessed. Benign prostatic hyperplasia (BPH) is a histological definition, BPO refers to a condition with blockage to urinary flow [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. With the increase of BPH prevalence, the rate of BPO and symptomatic patients with LUTS increases as well. Despite some differences in reported epidemiologic data across populations, overall prevalence has raised worldwide thought the last decades and is still increasing, due mainly to aging population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to the Global Burden of Diseases, Injuries and Risk Factors Study, from 1990 to 2021 there was a 122% increase in prevalence. Over the past 30 years, the burden of BPH in low socio-demographic index (SDI) regions have shown an upward trend. High-SDI regions exhibit a stable burden, suggesting limitations in effective treatment options [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In addition, Western populations have significantly higher prostate volumes than those from other parts of the world, particularly Southeast Asia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe raising prevalence of BPO in the aging population contributes to increasing the waiting list for patients with surgical indication. Clinical implications of long-term BPO are well known and complications may develop though time in terms of urinary tract infections (UTI), bladder stones, chronic and acute urinary retention (AUR), bladder diverticula, irritative symptoms, detrusor over- or underactivity. Quality of life of patients is overall impaired [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The time from diagnosis to treatment can affect surgical outcomes, therefore efforts should be done in order to reduce it. New minimally invasive surgical treatments (MISTs) have been developed in recent years. Among others, shorter operative time is a common described advantage. Patients selection is crucial and many factors should be considered, including prostate volume, presence of third lobe, bladder neck sclerosis, concomitant urethral stricture, comorbidities and the overall obstruction status [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAquablation (AquaBeam\u0026reg; Robotic System, Procept BioRobotics, Redwood City, CA, USA) has emerged as a reliable alternative to standard techniques, namely transurethral resection of the prostate (TURP) and endoscopic enucleation of the prostate (EEP). Speed of treatment is a known advantage, as typical of MISTs. However, Aquablation seems to cover a wider range of patients with surgical indication for BPO compared to other MISTs. In the present study we evaluated the outcomes of the first 100 patients treated by the same operator to assess the potential role of Aquablation as a safe and effective treatment to reduce the long waiting list of BPO patients in our public hospital.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003ePatients suffering from LUTS due to BPH with surgical indication were considered. Prostate volume\u0026thinsp;\u0026lt;\u0026thinsp;40 ml, coagulation impairments, non-suspendable anticoagulant therapy, neurogenic bladder were exclusion criteria. Patients with bladder stones, bladder diverticula without indication to diverticulectomy, prostate cancer, third lobe, indwelling catheter, concomitant bladder neck sclerosis or urethral stricure were included. Preoperatively, digital rectal examination, prostate specific antigen (PSA), prostate volume, haemoglobin (Hb) value, uroflowmetry with maximum flow rate (Qmax) measurement, post-void residual (PVR), International prostate symptoms score (IPSS) and Quality of Life (QoL) score were assessed. All patients had negative urine culture. In case of positive urine culture, antibiotic therapy was given to reach negativization. In cases with persistent positive urine culture, targeted antibiotic therapy was started 5 days before surgery.\u003c/p\u003e \u003cp\u003eAquablation was performed using the specific device, including the single-use handpiece and the dedicated transrectal ultrasound probe. The standardized technique was followed for every case. In case of concomitant urethral stricture, a cold-knife urethrotomy was performed at the beginning of the procedure. Bladder stones were treated before prostate ablation as well. Treatment planning was carried out under ultrasound guidance. After the ablation phase, a bipolar resectoscope was used to perform coagulation and to remove the residual parts of adenoma. A 3-way 22 Ch catheter was left in place at the end of the procedure with continuous irrigation.\u003c/p\u003e \u003cp\u003eAll procedures were performed in a single center (Sant\u0026rsquo;Anna hospital, Como, Italy) by the same surgeon (D.P.), with a high expertise in both TURP and prostate laser enucleation. The choice of treatment between Aquablation and EEP was based on patients\u0026rsquo; preference after adequate counseling, independently from the will to preserve ejaculation. Patients strongly motivated to preserve anterograde ejaculation were given indication to Aquablation. Intraoperative and postoperative data were collected. Total operative time was divided into ablation time (defined as the time from the beginning of the procedure to the removal of Aquablation handpiece) and resection/coagulation time (defined as the time from insertion of the resectoscope to the placement of the catheter, including the resection of residual parts of adenoma and coagulation). Functional outcomes after six months were assessed through IPSS score, Qmax, PVR and QoL score. Stress urinary incontinence was recorded as well as postoperative complications.\u003c/p\u003e \u003cp\u003eMean and standard deviation (SD) vs. numbers and proportions were used to describe continuous and categorical variables, respectively. Student\u0026rsquo;s t-test was used to test continuous variables conforming to a normal distribution. Data were analyzed with R software version 3.4.1 (R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, 100 consecutive patients were treated. Preoperative features are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Mean prostate volume was 90.9 ml (min 40 ml, max 300 ml). Preoperatively, patients had mean IPSS score 20.3, mean Qmax 8.3 ml/s, mean PVR 105.3 ml and mean QoL score 5.3. At preoperative blood test, mean haemoglobin (Hb) value was 13.7 g/dl. Among the treated patients, 39 (39.0%) had a third lobe, 24 (24.0%) had an indwelling catheter at the time of surgery and 6 (6.0%) had a bilateral hydronephrosis due to the lower urinary tract obstruction. 15 patients (15.0%) had one or more bladder stones, whereas in 2 cases (2.0%) a urethral stricture was incidentally found at the level of the bulbar urethra. In both cases a BPO was contextually present. At the time of surgery 71 patients (71.0%) were taking alpha-blockers, 43 (43.0%) were taking 5-alpha-reductase inhibitors and 23 (23.0%) were under combination therapy. Oral anticoagulation therapy was stopped and bridged to low-molecular-weight heparin (LMWH) in 5 patients (5.0%), whereas Clopidogrel was stopped without bridging in 3 cases. All patients assuming Acetylsalicylic acid didn\u0026rsquo;t stop the therapy before or after the surgery. Metastatic prostate cancer had been detected in one patient. Among the whole cohort only 16 patients (16.0%) were strongly interested in preserving anterograde ejaculation (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMean total operative time was 38.7 min. Specifically, mean ablation time was 14.3 min and mean resection/coagulation time 21.8 min. In the 2 cases with incidental finding of a bulbar urethral stricture, a cold-knife urethrotomy was performed to allow the insertion of the Aquablation handpiece. These two patients had a prostate volume of 100 ml and 90 ml, with a bulky third lobe. Therefore, the Aquablation treatment was performed as in both cases a BPO condition was present beside the stricture. Among the 15 patients (15.0%) with bladder stones, 11 underwent a Holmium:YAG laser cystolithotripsy, whereas 4 underwent open cystolithotomy before prostate ablation. No intraoperative complications occurred, but in 2 cases (2.0%) a technical problem was reported and solved through the replacement of the handpiece with a new one (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMean length of stay was 2.1 days, whereas mean catheterization time was 3.6 days. Mean Hb drop at first postoperative day (POD) was 1.5 g/dl. Six months after surgery mean IPSS score was 5.4, mean Qmax 18.6 ml/s, mean PVR 15.9 ml and mean QoL score 1.4. Only 1 patient (1.0%) needed a secondary treatment because of a residual portion of the third lobe causing LUTS, which was removed through an endoscopic bipolar resection. Among the 16 patients strongly interested in preserving anterograde ejaculation, all of them were satisfied from the treatment (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUrinary tract infection (UTI), defined as the presence of fever not otherwise justified, occurred in 1 case (1.0%) and required a prolonged hospitalization for a proper antibiotic therapy. 3 patients (3.0%) underwent acute urinary retention (AUR) without haematuria, whereas 2 patients (2.0%) underwent clots-induced retention. In all these cases a bladder catheter was placed and successfully removed 7 days afterwards. No patients required blood transfusions. Stress urinary incontinence, bladder neck sclerosis and urethral strictures were never reported during the follow-up (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAquablation consists on a robot-assisted endoscopic ablation of prostatic adenoma through a high-pressure heat-free saline waterjet. Treatment is planned with a specific software that allows a precise ultrasound contouring of the adenoma and it is performed under real-time monitoring by simultaneous cystoscopy and transrectal ultrasound [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Multiple studies have already shown the efficacy of Aquablation in improving urinary symptoms, with significant improvements in IPSS score, QoL score, Qmax and PVR at urofluometry [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Outcomes were comparable to TURP [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] even when dealing with big prostate volumes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The comparative study by Justo Quintas et al. demonstrated that both Aquablation and Holium:YAG laser enucleation of the prostate (HoLEP) significantly improved micturition at six months, with no statistically significant differences in functional outcomes. Aquablation had a notably lower rate of ejaculatory dysfunction (6.6% vs. 89.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which may offer a considerable quality-of-life advantage for certain patients. While HoLEP achieved greater reductions in prostate volume and PSA levels, Aquablation had a shorter tissue removal time and required less surgical expertise. Postoperative hemoglobin drop was higher with Aquablation, but transfusion rates remained low and comparable between both groups [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the available evidence on functional outcomes and the know advantages in terms of short learning curve [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], compared to the steeper one of laser enucleation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], Aquablation\u0026rsquo;s spread is still limited. Concerns don\u0026rsquo;t lie only on the economic burden, which anyway depends on the costs and refunds in each country, but also on the urologists\u0026rsquo; fear of leaving adenomatous tissue on the prostatic capsule and of perioperative bleeding. However, the fear of bleeding seems to be related to data from the very first experiences of Aquablation treatments, before the adoption of the haemostatic protocol [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, most surgeons don\u0026rsquo;t perceive many advantages in this technique, especially if they are already able in doing prostate enucleation. The aim of our study was to show a new perspective in which to find an additional benefit from the Aquablation treatment. In many countries, like in our public healthcare system, the waiting list of BPO patients with surgical indication is long, up to some years. Many factors concur to this issue, including the aging male population and few healthcare resources. Despite its benignity, prolonged BPO can severely affect bladder function and consequently surgical outcomes. In this scenario, given the already demonstrated functional outcomes and low complication rates, the significantly shorter operative time of Aquablation may contribute to solve this often underestimated problem.\u003c/p\u003e \u003cp\u003eFunctional outcomes were significantly improved when comparing postoperative data to preoperative values. Specifically, IPSS score showed a mean reduction of 14.9 points, Qmax a mean increase of 10.3 ml/s, PVR a mean decrease of 89.4 ml and QoL score a mean decrease of 3.9 points. These outcomes were not only comparable to those of previously published cohorts of Aquablation patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], but also to those of patients treated with endoscopic laser enucleation performed by the same operator irrespective of the type of laser used [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Only one patient had to be retreated six months after the procedure because of am obstructive residual part of the third lobe. No patients required alpha-blockers or 5-ARIs postoperatively. Regarding sexual function, all patients who declared to be strongly interested in preserving anterograde ejaculation, were satisfied from the result of the treatment. The success rate was therefore 100%, higher compared to other reports from literature [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, some aspects should be considered. Firstly, the number of patients interested in ejaculation was relatively low and only in these cases the apical paracollicular tissue preserved by the Aquablation machine was left in place. In all the other patients, the preservation of this tissue was minimized during the planning and the residual apical tissue was removed with the resectoscope to achieve a more complete treatment. Secondly, the rate of preservation of ejaculatory function should be evaluated considering only the interested patients, as this aspect influences the treatment planning by the surgeon. This may explain the higher success rate compared to other studies. Thirdly, in a previous publication we underlined the importance of patients\u0026rsquo; satisfaction beyond the simple persistence of seminal fluid at the time of ejaculation. Specifically, we showed that satisfaction rate was nearly 70% compared to an anterograde ejaculation rate of nearly 80% in a cohort of patients treated with ejaculation-sparing Thulium:YAG laser enucleation. Neverthless, both rates were higher among Aquablation patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. No patients reported significant changes in erectile function (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMean total operative time was quite short, accounting for 38.7 min. This data is in line with other reports [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and not surprising in itself. However, some considerations are due. Firstly, total operative time comprises the time needed to remove residual parts of adenoma to complete the treatment and the time needed to reach a proper haemostasis. This specific time that we called \u0026ldquo;resection/coagulation time\u0026rdquo; accounts for only 21.8 min, which means that the ablation phase managed to remove the majority of adenomatous tissue and that haemostatic control was easily reached. In our perspective this aspect should encourage urologists to move beyond the fear of bleeding. Secondly, the short operative time should be evaluated in light of the quite high mean prostate volume. If we consider the distribution within the cohort, median prostate volume was 80 ml with an interquartile range 70\u0026ndash;100 ml (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Indeed, prostates up to 300 ml were treated. In our opinion our experience shows that even large and very large prostates can be effectively treated with Aquablation with a short operative time. This brings to one of the key messages of the study, showing that Aquablation may play an important role in reducing the long waiting list of BPO patients by allowing a fast and effective treatment for a very wide range of prostate volumes. Thirdly, it is of note that this was our first experience with the technique. The operator had high experience with TURP and laser enucleation, but had never performed Aquablation procedures before. Given the low operative time, good functional outcomes and low complication rate, we can affirm that the learning curve of the procedure is short. Moreover, the strict standardization of the treatment makes it very easily reproducible. Lastly, the operative time was notably inferior to that of laser enucleation when considering prostates of any volume [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Similar differences were found with patients treated with laser enucleation by the same operator [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNotably, our cohort included patients with concomitant bladder stones or urethral stricture. In those cases urethrotomy, cystolithotomy or cystolithotripsy was performed before the Aquablation. This aspect underlines once more the high versatility of Aquablation procedure. Other MISTs have some limitations in inclusion criteria, starting from prostate volume and the presence of a third lobe. Most of them can be performed as outpatient procedures with mild sedation, but the presence of concomitant conditions like bladder stones imposes to switch to a deeper anesthesia and to perform the treatment in the operating room. This is not a problem with Aquablation, which must be performed under general or spinal anesthesia. To conclude, Aquablation is feasible in a very wide range of patients, not only in terms of prostate volume.\u003c/p\u003e \u003cp\u003eComplication rate was overall very low, with only 6 patients experiencing Clavien-Dindo grade II events. Interestingly, 5 patients underwent urinary retention after catheter removal. However, 3 of them had no haematuria and clots. In these cases the retention was likely due to bladder neck oedema or residual fluffy tissue from the waterjet ablation. On the contrary, 2 patients had clots-induced retention, which reinforces the concept of Aquablation as a safe treatment in terms of bleeding risk. Stress incontinence is a know problem after HoLEP, even though usually transient. Rates described in literature are different, with studies reporting up to 20% of incontinence 1 month after surgery and 10% after 3 months [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Despite many factors have been associated to postoperative incontinence [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], the mechanical distress on the sphincter due to the technical aspect of enucleation plays an important role [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This may explain the absence of stress incontinence within our cohort (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMean length of stay was comparable to previous reports on patients who underwent laser enucleation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. On the contrary, catheterization time seems slightly longer. In all cases the continuous irrigation was stopped the morning after the procedure and the decision to remove the catheter was taken upon the colour of urine starting from the day thereafter. Among Aquablation patients we found a higher tendency in having reddish urine during the first days after the procedure and this explains why they kept the catheter for a slightly longer time. This is in line also with the higher Hb drop at first POD, compared to patients undergoing laser enucleation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Despite this, neither blood transfusions nor surgical haemostasis were needed. This further underlines the proven safety of Aquablation in terms of bleeding risk and once again should help surgeons to overcome old fears.\u003c/p\u003e \u003cp\u003eSome limitations of the study need to be acknowledged. Firstly, the relatively low number of patients is a main concern. Secondly, there was no comparison with other treatments. However, the main aim of the study was to show the advantages of Aquablation from another interesting perspective, and not to add more comparative data to the ones already available. Thirdly, a cost analysis was not performed. However, this kind of analysis may be very complex, as it depends on the costs and refunds in each specific country and also within the same country. Cost effectiveness was beyond the purposes of our study. Fourthly, only one operator was involved. Mean operative time relates to surgeon\u0026rsquo;s proficiency and different operators may have different outcomes. Lastly, functional outcomes were evaluated six months after surgery. Very-long-term results are still lacking and will be the object of future studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAquablation has an established reliability as an alternative to standard techniques for BPO, also in patients not interested in preserving anterograde ejaculation. Micturition improvements are comparable to those of prostate laser enucleation and the rate of complications is very low, overtaking the old fear of bleeding. Mean total operative time is short, even taking into account the time needed to remove residual parts of the adenoma and to reach a proper haemostasis. Therefore, Aquablation may play a role in reducing the long waiting list of BPO patients with surgical indication within our public healthcare system.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerri D.: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePini G.: Supervision\u003c/p\u003e\n\u003cp\u003eMaruccia S.: Data analysis\u003c/p\u003e\n\u003cp\u003eMenozzi M.: Data collection or management\u003c/p\u003e\n\u003cp\u003eRivolta L.: Data collection or management\u003c/p\u003e\n\u003cp\u003eRomero-Otero J.: Protocol/project development, Supervision\u003c/p\u003e\n\u003cp\u003eSomani B.: Supervision\u003c/p\u003e\n\u003cp\u003eHerrmann T.: Supervision\u003c/p\u003e\n\u003cp\u003eDemirkiran E.D.: Data collection or management\u003c/p\u003e\n\u003cp\u003eBesana U.: Supervision\u003c/p\u003e\n\u003cp\u003eSangalli M.N.: Supervision\u003c/p\u003e\n\u003cp\u003ePastore A.L.: Protocol/project development, Superivision\u003c/p\u003e\n\u003cp\u003eAndreev R.: Data collection or management\u003c/p\u003e\n\u003cp\u003eGovorov A.: Supervision\u003c/p\u003e\n\u003cp\u003eBozzini G.: Protocol/project development, Supervision \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and/or Conflicts of interests/Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work\u003c/p\u003e\n\u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003eAll patients included in the study signed an informed consent. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoehrborn CG (2005) Benign prostatic hyperplasia: an overview. 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Transl Androl Urol 11:407\u0026ndash;420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/tau-21-1005\u003c/span\u003e\u003cspan address=\"10.21037/tau-21-1005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTricard T, Xia S, Xiao D et al (2023) Outcomes of holmium laser enucleation of the prostate (HoLEP) for very large-sized benign prostatic hyperplasia (over 150 mL): open simple prostatectomy is dead. World J Urol 41:2249\u0026ndash;2253. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00345-023-04486-w\u003c/span\u003e\u003cspan address=\"10.1007/s00345-023-04486-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFan X, Zhang J, Zhu H et al (2024) Predictive factors of stress urinary incontinence after Holmium Laser Enucleation of the Prostate: a magnetic resonance imaging-based retrospective study. Transl Androl Urol 13:1775\u0026ndash;1785. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/tau-24-71\u003c/span\u003e\u003cspan address=\"10.21037/tau-24-71\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgreda-Casta\u0026ntilde;eda F, Freixa-Sala R, Franco M et al (2024) Predictive factors of post-HoLEP incontinence: differences between stress and urgency urinary incontinence. World J Urol 42:281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00345-024-04984-5\u003c/span\u003e\u003cspan address=\"10.1007/s00345-024-04984-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarraz AM, Aldousari S, Eltafahny AI et al (2025) Laser-Driven Dissection Achieves Earlier Continence Recovery Than Blunt Dissection During Holmium Laser Enucleation of the Prostate. Low Urin Tract Symptoms 17:e70006. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/luts.70006\u003c/span\u003e\u003cspan address=\"10.1111/luts.70006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eDescriptive characteristics of 100 patients with lower urinary tract symptoms who underwent Aquablation\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eAquablation\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge, years\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e68.7 (7.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eProstate volume, ml\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eMin-Max\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eMedian (IQR)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e90.9 (19.3)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e40\u0026ndash;300\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e80 (70\u0026ndash;100)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIPSS score\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e20.3 (5.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eQmax, ml/s\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e8.3 (2.1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePVR, ml\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e105.3 (24.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eQoL score\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.3 (0.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePSA, ng/ml\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.4 (1.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHb, g/dl\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e13.7 (2.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eThird lobe\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e39 (39.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIndwelling catheter\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e24 (24.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBladder stones\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e15 (15.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrethral stricture\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (2.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHydronephrosis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (6.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAlpha-blockers assumption\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e71 (71.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e5-ARIs assumption\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e43 (43.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCombination therapy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e23 (23.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eProstate cancer\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (1.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnticoagulant therapy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (5.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntiplatelet therapy\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026bull; Acetylsalicylic acid\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026bull; Clopidogrel\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e17 (17.0)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e14 (14.0)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e3 (3.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eInterest in ejaculation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (16.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003eSD = Standard Deviation, IQR = Interquartile range, IPSS = International Prostatic Symptoms Score, Qmax = Maximum flow rate, PVR = Post-Void Residual, QoL = Quality of Life, PSA = Prostate-Specific Antigen, Hb = Haemoglobin, 5-ARIs = 5-alpha reductase inhibitors\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eIntraoperative and postoperative outcomes of 100 patients with lower urinary tract symptoms who underwent Aquablation\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eAquablation\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOperative time, min\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e38.7 (8.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAblation time, min\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e14.3 (2.1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eResection/Coagulation time, min\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e21.8 (6.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrethrotomy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (2.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCystolithotripsy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (11.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCystolithotomy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (4.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTechnical problems\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (2.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLength of stay, days\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.1 (0.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCatheterization time, days\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.6 (1.3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHb drop at 1st POD, g/dl\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.5 (0.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e6-month IPSS score\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.4 (2.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e6-month Qmax, ml/s\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e18.6 (2.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e6-month PVR, ml\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e15.9 (13.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e6-month QoL score\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.4 (0.3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnterograde ejaculation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (100)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSecondary treatment\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (1.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUTI\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (1.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAUR\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (3.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eClots retention\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (2.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBlood transfusions\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eStress incontinence\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003eSD = Standard Deviation, Hb = Haemoglobin, POD = Post-Operative Day, IPSS = International Prostatic Symptoms Score, Qmax = Maximum flow rate, PVR = Post-Void Residual, QoL = Quality of Life, UTI = Urinary Tract Infection, AUR = Acute Urinary Retention\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Aquablation, AquaBeam, Benign prostatic obstruction, Benign prostatic hyperplasia","lastPublishedDoi":"10.21203/rs.3.rs-8756172/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8756172/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo assess the efficacy and safety of Aquablation treatment in a single-center same-operator cohort and its potential role in reducing the long waiting list of patients with surgical indication for benign prostatic obstruction (BPO).\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e \u003cp\u003ePatients with surgical indication for BPO underwent Aquablation. All patients were treated by the same operator (D.P.) in a single center (Sant\u0026rsquo;Anna hospital, Como, Italy). Ablation was performed according to the standardized technique and coagulation through bipolar resectoscope was done in all cases. Perioperative parameters, functional outcomes and complications were assessed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e100 consecutive patients were included. Mean prostate size was 90.9 ml (min 40 ml, max 300 ml). Mean total operative time was 38.7 min, with a mean ablation time of 14.3 min and coagulation time of 21.8 min. No intraoperative complications were reported. In 2 cases a technical problem occurred and solved by replacing the handpiece. Postoperatively, 3 patients (3.0%) underwent urinary retention without haematuria, 2 patients (2.0%) underwent clots-induced retention, 1 patient (1.0%) developed an infection. No urethral strictures, nor bladder neck sclerosis were diagnosed during the follow-up, as well as no cases of stress urinary incontinence. Functional outcomes significantly improved compared to the preoperative evaluation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAquablation proved to be not only a fast treatment when performed by the same hands, but also a reliable option in terms of efficacy and safety, with good functional outcomes and very low complication rates. The shorter operative time provided by this technique may help to reduce the long waiting list of BPO patients with surgical indication.\u003c/p\u003e","manuscriptTitle":"Can Aquablation treatment help to effectively reduce the long waiting list of patients with surgical indication for benign prostatic obstruction in a fully public healthcare system? Results of the first 100 cases from a single-center same-operator cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 17:39:36","doi":"10.21203/rs.3.rs-8756172/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"97982394244558374847497385575339957500","date":"2026-04-01T06:44:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T12:06:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T20:28:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T17:39:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2026-02-01T12:30:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"44708f47-4787-467d-8448-5fb6273c6934","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T17:39:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 17:39:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8756172","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8756172","identity":"rs-8756172","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}