Aquablation vs. holmium laser enucleation of the prostate for benign prostatic hyperplasia: a 150-patients prospective comparative multicenter study.

Abstract

Background: The aim of this study was to compare the efficacy and safety of Aquablation^® with those of holmium laser enucleation of the prostate (HoLEP) for the treatment of patients with benign prostatic hyperplasia (BPH).

Methods: Prospective comparative non-randomized multicenter study conducted between July 2021 and July 2023, consecutive patients undergoing BPH surgery were enrolled to each group. Patients had moderate to severe lower urinary tract symptoms (LUTS), International Prostate Symptom Score (IPSS) ≥8, maximum urinary flow rate (Qmax) ≤15 mL/s, prostate volume ≥30 mL ≤120 mL, and BPH medical therapy failure. Primary outcome was short-term efficacy measured by IPSS, IPSS-QoL, Qmax, post-void residual volume (PVR), prostate-specific antigen (PSA); secondary outcome was safety (intra and post-operative complications, ejaculatory dysfunction, continence, blood transfusions). A six-month follow-up was performed.

Results: Of 150 patients (75:75) enrolled, both groups showed improvements (P<0.05) in IPSS, IPSS-QoL, Qmax, and PVR at six months. No significant differences were observed between HoLEP and Aquablation^® in IPSS (7.6±6.9 vs. 5.05±4.9 points, P=0.11), IPSS-QoL (1.7±1.6 vs. 1.3±1.6 points, P=0.16), Qmax (28.6±8.8 vs. 23.8±9.3 mL/sec, P=0.12), and PVR (7.2±8.2 vs. 20.3±22.6 mL, P=0.19) at six months. No intraoperative complications occurred. Postoperative hemoglobin drop was higher in Aquablation^® group (2.6±1.33 vs. 0.4±0.67 g/dL, P<0.001), with no statistically significant differences in transfusion rate (1.3 vs. 1.3%, P=0.31). Ejaculatory dysfunction rate was significantly lower in Aquablation^® (6,6%) than HoLEP (89.3%, P<0.001). Mean prostate volume was (mean±SD) 81.8±37.4 and 71.9±34.8 mL (P=0.08) in HoLEP and Aquablation^® groups, respectively. Holep demonstrated a smaller prostate volume after treatment (18.1±6.5 vs. 46.5±25.02 mL P<0.001) as well as a significantly greater reduction and lower levels of PSA (1.2±1.4 vs. 2.65±2.8 ng/mL, P<0.001). Aquablation^® demonstrated significantly shorter tissue removal time (5.5±2.4 vs. 22.4±9.8 min, P<0.001), but no difference in total operative time (49.1±15 vs. 43.9±26.8 min, P=0.052).

Conclusions: HoLEP and Aquablation^® show similar effectiveness and safety for BPH-related-LUTS at 6 months. Aquablation^® has lower ejaculatory dysfunction rates. Larger randomized trials and with longer follow-up time are needed for validation.