Editorial Comment on Optimizing Patient Selection for Aquablation During the Initial Adoption Phase: Prostate Smaller Than 100  <scp>mL</scp>

Aquablation has been increasingly adopted worldwide, with real-world data demonstrating reduced bleeding-related postoperative complications [1]. However, practical guidance regarding optimal patient selection during the initial adoption phase remains insufficiently defined. In this context, the study by Koike et al. provides timely and clinically meaningful evidence by proposing prostate volume-based criteria to support the safe and efficient implementation of Aquablation during early experience [2]. In this study, prostate volume was the sole independent predictor of operative time and postoperative bladder irrigation volume, leading to a proposed threshold of < 100 mL for initial cases. This finding substantiates the common practical experience of surgeons during the early learning phase, wherein moderate-sized prostates are associated with improved procedural efficiency and reproducibility. The relationship between prostate volume, patient background, and perioperative outcomes has also been explored in previous real-world studies. Ringler et al. retrospectively compared Aquablation outcomes in patients with prostate volume ≥ 150 mL versus those with a volume < 150 mL, reporting significantly longer operative times (72 vs. 57 min, p < 0.001) and a greater hemoglobin decline (2.45 vs. 1.54 g/dL, p = 0.004) in the larger-volume group [3]. Although transfusion rates were similar, reoperation rates were higher for prostates ≥ 150 mL (24% vs. 11%, p = 0.043). In addition, Murad et al. analyzed outcomes in patients aged ≥ 80 years versus those aged < 80 years, demonstrating significantly higher rates of takeback for cystoscopy with clot evacuation (4.4% vs. 1.9%, p = 0.034), transfusion (2.9% vs. 0.5%, p = 0.0027), and 30-day readmission (4.2% vs. 0.7%, p = 0.020) in the older cohort [4]. Collectively, these findings suggest that larger prostate volume and advanced age warrant cautious patient selection during initial adoption. Recent evidence also supports the feasibility of same-day discharge following Aquablation. Zorn et al. demonstrated that, in an ambulatory surgery center setting, 59 of 60 (98%) patients were successfully discharged on the same day without requiring transfusion or return to the operating room [5]. These outcomes were achieved through meticulous focal bladder neck cautery and structured perioperative pathways, highlighting the critical role of hemostatic technique in enabling streamlined postoperative care. Taken together, this study provides a clear and practical framework for patient selection during early Aquablation adoption. A prostate volume threshold of < 100 mL supports procedural safety and reproducibility. Although this study was based on a retrospective analysis at a single center, the findings may support the safe expansion of the technique to older patient populations and same-day discharge pathways. Taiki Kato: conceptualization, writing – original draft, writing – review and editing. The author declares no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.