Optimizing Patient Selection for Aquablation During the Initial Adoption Phase: Prostates Smaller Than 100 mL

Abstract

Objectives

To identify optimal candidates for Aquablation during the initial adoption phase by determining predictors of operative time and bladder irrigation volume to guide safe implementation.

Methods

We retrospectively analyzed 123 patients who underwent Aquablation between 2023 and 2025 during the initial implementation of this technique by Aquablation-naïve urologists at our institution. Patients with short operative times and low irrigation volumes were considered optimal candidates. Preoperative variables were assessed using multivariable linear regression. Because prostate volume (PV) demonstrated the strongest association with operative time and irrigation volume, post hoc exploratory locally estimated scatterplot smoothing (LOESS) analysis was performed to define a data-driven PV threshold, and perioperative outcomes were compared above and below this threshold.

Results

PV (median, 78 mL; interquartile range, 60–100 mL) was the only independent predictor of long operative times and great irrigation volumes. LOESS identified a PV threshold near 80 mL for bladder irrigation volume and 100 mL for operative time. Patients with PV < 100 mL had more favorable perioperative outcomes. Compared with PV ≥ 100 mL, PV < 100 mL had shorter operative times (median, 56 vs. 81 min; p < 0.05), lower irrigation volumes (median 9000 vs. 14 000 mL; p < 0.05), and smaller hemoglobin reductions (−0.9 vs. −1.6 mg/dL; p < 0.05); rates of Clavien-Dindo ≥ 3 adverse events, transfusion, and refulguration did not differ.

Conclusion

A PV < 100 mL appears to be a practical criterion for safe early adoption of Aquablation; accurate preoperative estimation of PV is therefore essential.