Men with urinary symptoms caused by an enlarged prostate often search online, asking:
- “Am I a good candidate for Aquablation?”
- “Is Aquablation right for me?”
- “Who should not have Aquablation?”
These are important questions. Aquablation is not a one-size-fits-all treatment. This article explains who Aquablation is suitable for, who benefits most, and when it may not be the best option, combining clinical evidence with real-world surgical decision-making.
What Is Aquablation, and Why Does Patient Selection Matter?
Aquablation is a minimally invasive surgical treatment for benign prostatic hyperplasia (BPH). BPH means non-cancerous enlargement of the prostate gland. As the prostate enlarges, it can compress the urethra (the urine pipe), leading to urinary symptoms.
Aquablation uses:
- A high-pressure water jet to remove prostate tissue
- Real-time ultrasound imaging to visualise the prostate
- Robotic planning to control exactly where tissue is removed
Why patient selection matters:
- Prostates differ in size and shape
- Symptoms vary in severity
- Sexual priorities differ between men
- Medical conditions affect safety and outcomes
Correct patient selection improves:
- Symptom relief
- Safety
- Long-term satisfaction
What Prostate Size Is Aquablation Suitable For (30–150 ml and Beyond)?
Standard prostate size range: 30–150 millilitres (ml)
Aquablation is suitable for a wide range of prostate sizes, which is one of its key advantages.
- Most suitable range: 30–150 ml
- Effective for medium and very large prostates
- Outcomes remain consistent as prostate size increases
Why prostate size matters:
- Larger prostates cause more bladder outlet blockage
- Many procedures become less effective or riskier as size increases
- Aquablation relies on robotic mapping rather than surgeon hand technique alone
Evidence from clinical trials
Aquablation was evaluated in two major studies:
- WATER I trial: prostates approximately 30–80 ml
- WATER II trial: prostates 80–150 ml
These studies showed:
- Significant improvement in urinary symptoms
- Improved urine flow
- Acceptable bleeding risk
- High preservation of ejaculation
Symptom scores improved by 15–20 points on average, which is considered clinically meaningful.
Real-world surgical experience
Although the original trials included prostates up to 150 ml, Aquablation is now used in routine clinical practice. In carefully selected cases, experienced centres have treated prostates larger than this outside the original trial setting.
Important for patients to understand:
- This is not routine
- Outcomes depend on prostate anatomy, not size alone
- Decisions must be individualised
How Severe Do Urinary Symptoms Need to Be for Aquablation to Work?
Aquablation is best suited for men with moderate to severe urinary symptoms.
Symptom severity is measured using the International Prostate Symptom Score (IPSS).
IPSS is a simple questionnaire that:
- Scores symptoms from 0 to 35
- Higher scores mean worse symptoms
- Helps guide treatment decisions
IPSS ranges:
- Mild: 0–7
- Moderate: 8–19
- Severe: 20–35
Aquablation is usually considered when:
- Symptoms affect quality of life
- Medication has failed or caused side effects
Common symptoms include:
- Weak urine stream
- Difficulty starting urination
- Stopping and starting
- Urgency
- Nocturia (waking at night to pass urine)
Why symptom severity matters:
- Surgery should offer meaningful benefit
- Aquablation provides rapid and durable symptom relief rather than temporary improvement
Does Age Matter When Deciding if Aquablation Is Right for You?
Age alone is not a limiting factor
Aquablation can be suitable for:
- Younger men
- Older men
- Provided they are fit for anaesthesia
Typical age range:
- Late 40s to well into the 80s
Why age is less important than overall health:
- Procedure time is usually under 1 hour
- Minimal heat damage reduces recovery time
- Blood loss is predictable and controlled
Younger men often prioritise sexual function. Older men often have larger prostates. Aquablation addresses both concerns.
Is Aquablation the Right Choice If Preserving Ejaculation Matters to You?
This is one of the strongest reasons men choose Aquablation.
Ejaculatory function refers to the release of semen during orgasm. Many prostate operations damage the structures responsible for this.
Rates of ejaculatory loss:
- Traditional TURP: 65–75%
- Laser prostate surgery: 50–70%
- Aquablation: ejaculation preserved in 80–90%
Why Aquablation protects ejaculation:
- Robotic planning avoids key anatomical structures
- No heat damage
- Precise depth control
Erectile function (the ability to get and maintain an erection) is generally unchanged from baseline.
This makes Aquablation suitable for:
- Sexually active men
- Younger patients
- Men distressed by sexual side effects of medication
Which Medical Conditions Affect Whether Aquablation Is Safe for You?
Aquablation may still be suitable for men with:
- High blood pressure
- Diabetes
- Heart disease (once optimised)
- Obesity
- Mild kidney impairment
Why:
- Short operating time
- Reduced thermal injury
- Controlled bleeding
Some men taking blood-thinning medication may still be suitable, depending on individual risk.
Each condition must be assessed individually, but Aquablation is often possible when other procedures are less suitable.
Can Aquablation Be Performed After Previous Prostate Surgery?
Aquablation can sometimes be considered after:
- Previous TURP
- Previous laser prostate surgery
However, results are less predictable because:
- Normal anatomy may be altered
- Scar tissue can affect accuracy
- Bleeding risk may be higher
It is most suitable when:
- Previous surgery was many years ago
- Residual prostate tissue is clearly defined
- Symptoms are significant and persistent
Careful imaging and counselling are essentials.
When Is Aquablation Not the Best Option?
Aquablation may not be ideal if:
- The prostate is very small (<30 ml)
- Symptoms are mild
- There is an active urine or prostate infection
- Prostate cancer is suspected or confirmed
- There is a severe bleeding disorder
- Anaesthesia is unsafe
In these cases, alternatives such as medication, UroLift, Rezūm, or laser surgery may be more appropriate.
Being clear about who should not have Aquablation builds trust and improves outcomes.
Does Aquablation Provide Long-Term Symptom Relief?
Aquablation removes prostate tissue rather than shrinking it.
Long-term data shows:
- Retreatment rates around 4–5% at 5 years
- Sustained symptom improvement
- Durable improvement in urine flow
This makes Aquablation suitable for men who:
- Want to stop long-term medication
- Prefer a one-off procedure
- Want lasting symptom control
Who Is Aquablation Most Suitable For?
Aquablation is most suitable for men who:
- Have moderate to severe urinary symptoms
- Have a prostate between 30 and 150 ml
- Want strong symptom relief
- Value preservation of ejaculation
- Want a durable surgical solution
- Are fit for a short anaesthetic
It may not be ideal for men with mild symptoms or very small prostates.
Reliable Sources and Further Reading
- NICE BPH guidance
- European Association of Urology (EAU) Guidelines on BPH
