Aquablation Compared with Simple Prostatectomy for Prostate Volumes >80 Grams

<b><i>Introduction and Objectives:</i></b> Aquablation (Aqua) is a novel technique for treating benign prostatic hyperplasia and lower urinary tract symptoms. This study compares Aqua to simple prostatectomy (SP), analyzing functional urinary outcomes, adverse events (AE), and retreatment rates. <b><i>Methods:</i></b> A single-institution retrospective chart review was conducted for men undergoing open/robotic SP or Aqua from 2017 to 2023 for prostates >80 mL. Data collected included blood transfusions, AE, retreatment rates, postoperative medication use, and International Prostate Symptom Score (IPSS) with quality-of-life (QOL) indicator. To address differences in baseline characteristics, including prostate size, we applied inverse probability of treatment weighting (IPTW). Statistical analyses were performed using R 4.4.0. Results are presented as IPTW-adjusted comparing SP to Aqua using Fischer's exact test and analysis of variance reported as beta (B) for continuous variables and odds ratios (OR) for categorical variables with 95% confidence intervals (CI). <b><i>Results:</i></b> In total, 172 patients were studied: 111 Aqua and 61 SP. Groups were well-matched for body mass index (Aqua 28.77 <i>vs</i> SP 28). Aqua patients were older (73.04 <i>vs</i> 68.89), had smaller prostates (135.46 <i>vs</i> 186.53 mL), and lower preoperative urinary retention (21.8% <i>vs</i> 47.5%). Baseline characteristics between groups were adjusted using IPTW. SP outperformed Aqua in 1-year IPSS scores (<i>B</i> = -3.4, CI: -5.7, -1.1, <i>p</i> = 0.005), whereas QOL was comparable (<i>B</i> = -0.46, CI: -1.3, 0.33, <i>p</i> = 0.2). SP patients continued alpha-blockers less often postoperatively (<i>B</i> = -0.27, CI: -0.39, -0.41, <i>p</i> = 0.001). SP showed higher blood transfusion rates (OR = 4.22, CI: 1.64, 13.2, p = 0.006), longer hospital stays (<i>B</i> = 1.7, CI: 1.0, 2.4, <i>p</i> < 0.001), and longer operating times (<i>B</i> = 119, CI: 101, 135, <i>p</i> < 0.001). SP had lower retreatment rates (OR = 0.46, CI: 0.23, 0.87, <i>p</i> = 0.019). AE were not significantly different (<i>p</i> = 0.8). <b><i>Conclusions:</i></b> Aqua outperformed SP for blood transfusions, hospital stay, and operative time. SP outperformed Aqua for retreatment rates, IPSS scores at 1-year follow-up, and reliance on alpha-blockers.