Is Scandinavia ready for Aquablation? Reflections on the WATER III Trial

Ten years after the first-in-human study, Aquablation has reached another stage in its development.Previous randomised trials established its role against Transurethral resection of prostate (TURP).WATER III asks a different question: how does Aquablation compare with enucleation, the guideline-recommended endoscopic approach for large prostates?[1].This is an important question in Scandinavia, where treatment options for very large prostates are largely limited to endoscopic enucleation, robot-assisted simple prostatectomy, and, in selected patients, prostatic artery embolisation [2,3].WATER III therefore addresses a genuine evidence gap.Aquablation combines real-time ultrasound imaging with robotically controlled waterjet resection.Unlike laser enucleation, tissue resection is automated once the surgeon has mapped the treatment plan.Yet uptake in Scandinavia has been relatively slow compared with North America.Is this simply because evidence in large prostates has been limited or are implementation and health-system factors equally important?WATER III included 202 men with prostates between 80 and 180 mL.Symptom improvement was similar after Aquablation and laser enucleation, with no difference in major complications.Aquablation preserved ejaculation more often, and no patient had stress urinary incontinence at 3 months.Laser enucleation produced greater improvement in urinary flow and removed substantially more tissue.Does this change practice?Probably not yet.Laser enucleation is supported by mature long-term evidence, with established durability and low retreatment rates.Comparable evidence for Aquablation in very large prostates is not yet available.The planned 5-year follow-up of WATER III will therefore be important in determining whether these encouraging early functional outcomes are accompanied by durable symptom relief and low retreatment rates.The 3-month comparison also requires caution.Continence after enucleation may continue to improve beyond this period.In our practice, continence is routinely assessed at 6 months for this same reason.Moreover, recruitment during the COVID-19 pandemic meant that not all patients underwent randomisation, resulting in a hybrid randomised and non-randomised design, with both cohorts incorporated into the Bayesian analysis.