Editorial Comments to “Optimizing Patient Selection for Aquablation During the Initial Adoption Phase: Prostates Smaller Than 100  <scp>mL</scp> ”

Minimally invasive surgical therapies (MISTs) have rapidly reshaped the surgical management of benign prostatic hyperplasia over the past decade. As accumulating evidence has demonstrated favorable functional outcomes with reduced perioperative morbidity, an increasing number of institutions are expected to adopt MISTs in routine clinical practice. In this context, establishing safe and practical strategies for the early adoption phase has become an important clinical issue. Aquablation offers several advantages, including high reproducibility, applicability to relatively large prostate volumes (PVs), and favorable functional outcomes [1]. Nevertheless, as with any newly introduced surgical technology, concerns regarding operative efficiency, perioperative complications, and appropriate patient selection are particularly relevant during the initial learning phase to ensure patient safety and facilitate institutional learning. Evidence from the landmark WATER and WATER II randomized controlled trials has demonstrated that patients with larger PV (80–150 mL) experience significantly longer operative and irrigation times, as well as higher complication rates and prolonged catheterization, compared with those with PV ≤ 80 mL [2]. These findings established PV as a key determinant of procedural complexity and safety in Aquablation. However, an optimal volume threshold for safer case selection during early adoption has not been clearly defined. In this issue, Koike et al. provide important new insights [3]. Using LOESS smoothing and receiver operating characteristic analyses, the authors found optimal PV cutoffs of approximately 98 mL for prolonged operative time and 80 mL for increased irrigation volume. They also demonstrated patients with PV < 100 mL had significantly shorter operative times, lower irrigation volumes, smaller hemoglobin changes, and shorter hospital stays than those with PV ≥ 100 mL. This simple and clinically intuitive threshold aligns well with prior trial data and offers practical guidance for institutions preparing to introduce Aquablation. Previous reports have suggested that Aquablation may require longer operative times and carry a higher risk of major complications compared with other MISTs, such as water vapor thermal therapy or prostatic urethral lift [4]. In this setting, prioritizing safety and efficiency by selecting patients with PV < 100 mL for initial cases appears to be a reasonable approach. Overall, this study provides timely and pragmatic guidance for the safe introduction of Aquablation into clinical practice. Future studies evaluating the interaction between cumulative surgical experience and optimal PV thresholds may further refine adoption strategies and support safer, stepwise implementation of this technology as MIST continues to expand globally. The author takes full responsibility for this article. The author declares no conflicts of interest. This article is linked to Koike et al. papers. To view this article, visit https://onlinelibrary.wiley.com/doi/10.1111/iju.70373.