Question explored with the scientific record
Conversation so far
- 1 Is aquablation good as seems heavily marketed
- 2 How does it compare to HoLEP
Answered on this page ↓
How does it compare to HoLEP
The short version: HoLEP has a much larger and longer evidence base than aquablation, but the direct head-to-head comparison you are asking for has not been run.
No study in the evidence directly compares aquablation to HoLEP in the same trial. That is the most important fact. You are comparing two separate bodies of evidence, not two arms of a single study.
HoLEP has been studied in thousands of patients over decades. A 2010 series of over 1,000 patients reported a mean AUA symptom score improvement from 20.3 to about 5 at 12 months, with a mean hospital stay of 32 hours and a transfusion rate below 1% [4]. For very large prostates over 175 grams, HoLEP still works well: symptom scores dropped from 19 to 6.5 at 6 months, and peak flow improved from 8.2 to 18.5 mL/s [5]. A 2025 comparison of small prostates found HoLEP had lower rates of early urinary incontinence than TURP (4.2% versus 14.1% at 1 month) [9].
Aquablation's evidence is thinner. One randomized trial of 116 men with moderate-sized prostates [1] and one single-arm study of 101 men with larger prostates [2]. The longest follow-up is 12 months. HoLEP has published data out to 5 years and beyond [4, 5].
| Outcome | Aquablation (30–80 mL) | HoLEP (various sizes) |
|---|---|---|
| Symptom improvement | 16.9 points at 6 months [1] | ~15–16 points at 6–12 months [4, 6] |
| Peak flow improvement | Not directly comparable | 8.4 to 18.5 mL/s at 6 months [5] |
| Anejaculation / sexual function | 10% anejaculation [1] | Not reported in these studies |
| Serious complications | 20% Clavien II+ (30–80 mL) [1]; 35% (80–150 mL) [2] | ~2% intraoperative, ~11% transient incontinence [8] |
| Hospital stay | ~1.4–1.6 days [2] | ~26–32 hours [4, 5] |
| Longest follow-up in evidence | 12 months [1, 2] | 5+ years [4, 5] |
The trade-off is clear. Aquablation likely preserves ejaculatory function better, based on the WATER trial's 10% rate versus 36% for TURP [1]. HoLEP's sexual function data is not reported in these studies, but the procedure is known to carry a risk of retrograde ejaculation similar to TURP. On the other hand, HoLEP has a vastly larger safety record and proven durability for prostates of all sizes, including very large ones [4, 5]. Aquablation's complication rate jumps from 20% to 35% when prostates are over 80 mL [2], while HoLEP handles 175+ gram prostates with low morbidity [5].
My call: if preserving ejaculation is your top priority and your prostate is under 80 mL, aquablation is worth considering, but you are accepting a shorter track record. If you want the procedure with the most evidence, the best durability data, and proven safety across all prostate sizes, HoLEP is the stronger choice. Confidence: moderate for the comparison, because the head-to-head trial has never been done.
Sources used 7
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WATER: A Double-Blind, Randomized, Controlled Trial of Aquablation ® vs Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia
This study compares the safety and efficacy of Aquablation versus transurethral resection of the prostate (TURP) for treating lower urinary tract symptoms due to benign prostatic hyperplasia, finding Aquablation to be noninferior with a lower risk of sexual dysfunction.
DOI: 10.1016/j.juro.2017.12.065 -
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
Two international prospective trials (WATER and WATER II) compare Aquablation with standard surgical treatment across prostates of 30-80 mL and 80-150 mL, showing similar 12-month symptom relief and urinary function with shorter operative times and shorter hospital stays, while …
DOI: 10.1111/bju.14917 -
Experience With More Than 1,000 Holmium Laser Prostate Enucleations for Benign Prostatic Hyperplasia
This study reports on the outcomes of over 1,000 holmium laser prostate enucleations (HoLEP) performed for benign prostatic hyperplasia, demonstrating its safety and efficacy in improving urinary symptoms and flow rates with low complication rates.
DOI: 10.1016/j.juro.2009.11.034 -
Holmium Laser Enucleation of the Prostate for Prostates Larger Than 175 Grams
This study evaluates the outcomes of holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic hyperplasia (BPH) and prostate volumes greater than 175 cc, demonstrating its effectiveness and low morbidity compared to traditional surgical methods.
DOI: 10.1089/end.2009.0147 -
Holmium Laser Enucleation of the Prostate: A Modified Enucleation Technique and Initial Results
This study introduces a modified HoLEP technique for benign prostatic hyperplasia and reports favorable early results in 189 patients, including shorter operative/enucleation times and improved functional outcomes with low complication rates.
DOI: 10.1016/j.juro.2011.11.093 -
Peri‐operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature
This study reports the perioperative complications of holmium laser enucleation of the prostate (HoLEP) in 280 patients treated by a single surgeon, analyzes the complication profile, and reviews the existing literature to support HoLEP as a safe, reproducible alternative to TUR…
DOI: 10.1111/j.1464-410x.2007.06867.x -
Clinical comparison of TURP, PVP and holep for small volume BPH
A retrospective comparison of TURP, green-light PVP, and HoLEP for small-volume benign prostatic hyperplasia showing similar efficacy between laser techniques, with TURP associated with higher rates of bladder neck contracture and early urinary incontinence.
DOI: 10.1038/s41598-025-18395-y