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A prospective multicenter comparison between holmium laser enucleation ofthe prostate (holep) and aquabeam robotic system for the treatment of benign prostatic hyperplasia

Introduction and objective

Prostatic enucleation is considered the gold standard for the surgical treatment of benign prostatic hyperplasia(BPH). Emerging minimally invasive technologies aim to maintain functional results whilst decreasing adverseevents. Aquablation is a novel heat-free therapy using a high-velocity waterjet and real-time ultrasound imaging with robotic assistance for removal of prostate tissue. Our objective is to compare for the first time the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) and Aquablation for the surgical treatment of BPH.


Prospective comparative non-randomized multicenter study of 100 consecutive patients treated with HoLEP or Aquabeam system. HoLEP was performed by 3 expert surgeons and a standard Aquablation was performed with the AquaBeam system by 2 surgeons. Inclusion criteria: patients with moderate/severe symptoms due to BPH. Exclusion criteria: previous surgical treatment for BPH, concomitant urethral stenosis, bladder tumor, or lithiasis and prostates >120cc. The data were prospectively collected. A descriptive analysis was performed and data onthe efficacy and safety of both techniques were compared.


The groups are comparable (p>0.05) in prostate size; mean HoLEP vs Aquabeam; 78.95 vs 77.10cc, preoperative IPSS (24.26 vs 22.68), Q max (8.44 vs 9.83) and IIEF15 (41.10 vs 58.15), as well as in the rest preoperative variables (age, personal history, PSA, ASA risk and ejaculation function). Treatment time was longer in the HoLEP group with a mean of 23 minutes for enucleation vs. 5.99 minutes in the Aquabeam group (p<0.05). However, no statistically significant differences in total operating theatre time (53 vs 60 minutes). No intraoperative complications. More significant haematic loss (haemoglobin drop) in the Aquabeam group but none of the patients required a transfusion. As for the perioperative outcomes: no differences were observed between the two groups in bladder catheterization time: 30.53 vs 46.91 hours and hospitalization time 1.4 vs 1.74 days. No differences in rehospitalization, emergency room visits, recatheterization, or infection. At the 6-month follow-up, no statistically significant differences were found in Q-max, BOO, IPSS, complication rates or incontinence. On the other hand, statistically significant differences were found in prostate volume (16.86 vs 42.43 p=0.012) and PSA(0.51 vs 4.2 p<0.01). All patients with Aquabeam retain anterograde ejaculation, while only one patient in the HoLEP group preserves it.


The Aquabeam System appears to be a safe technique that provides comparable early functional and perioperative results to HoLEP with a similar complication rate. Advantages of this technique include reduced resection time as well as the possibility of preserving sexual function.