The impact of prostate size on outcomes of aquablation: a prospective study

PURPOSE: To evaluate whether prostate size influences perioperative, urinary, and sexual outcomes following Aquablation for benign prostatic hyperplasia (BPH), by comparing men with prostates < 80 cc and ≥ 80 cc treated within a prospective real-world cohort. METHODS: This prospective, single-center cohort study included consecutive men undergoing Aquablation between 2023 and 2025. Patients were stratified by prostate volume (< 80 cc vs. ≥80 cc). Baseline characteristics, perioperative parameters, and functional outcomes were assessed using validated instruments, including IPSS, IPSS-QoL, irritative subscore, ICIQ-SF, IIEF-EF, MSHQ-EjD, and MSHQ-bother, at baseline and at 3, 6, 12, and 24 months. Complications were graded according to the Clavien-Dindo classification. RESULTS: A total of 628 men were included (324 with prostates < 80 cc and 304 with prostates ≥ 80 cc). Men with larger prostates had higher rates of preoperative catheter dependence (34% vs. 18.2%, p < 0.001). Operative time (40.6 ± 14.1 vs. 36.2 ± 12.6 min, p = 0.001) and hospitalization duration (2.5 ± 1.5 vs. 2.09 ± 0.8 days, p < 0.001) were longer in the ≥ 80 cc group. Both cohorts demonstrated marked and durable improvement in urinary symptoms, with mean IPSS improving from 24.5 to 6.7 in the < 80 cc group and from 24.9 to 6.0 in the ≥ 80 cc group at 24 months. Irritative symptom scores improved from 10.3 to 3.5 and from 10.5 to 2.1, respectively (p < 0.001). Sexual outcomes remained stable across prostate sizes, with preserved erectile function and low ejaculatory bother scores. High-grade complications (Clavien-Dindo III-IV) were uncommon and comparable between groups (2.7% vs. 4.3%), while reoperation rates remained low (3.1% vs. 3.9%). CONCLUSION: Aquablation provides durable symptom relief with preservation of sexual function across a broad range of prostate volumes, supporting its role as a size-independent surgical treatment option for BPH.