Aquablation versus HoLEP: Propensity score matching analysis of functional outcomes and ejaculation preservation

Abstract

Purpose: This study aimed to compare the clinical outcomes of Aquablation and Holmium Laser Enucleation of the Prostate (HoLEP) for the treatment of benign prostatic hyperplasia (BPH), with emphasis on functional improvement, ejaculatory preservation, and perioperative safety.

Materials and methods: We retrospectively analyzed data from January 2023 to March 2024, excluding patients with follow-up shorter than 3 months. Propensity score matching was performed using age, prostate volume, and preoperative prostate-specific antigen (PSA). Pre- and postoperative outcomes included International Prostate Symptom Score, Overactive Bladder Symptom Score, maximum flow rate (Qmax), post-void residual urine volume (PVR), PSA, and MSHQ-EjD (Male Sexual Health Questionnaire-Ejaculatory Dysfunction)-based ejaculatory grading (0-3). Paired t-tests, Wilcoxon signed-rank tests, McNemar's test, and Mann-Whitney U test were applied as appropriate.

Results: A total of 104 patients were included, with 34 matched pairs. Both procedures significantly improved lower urinary tract symptoms, with no significant differences in symptom score changes or PVR. HoLEP resulted in greater improvements in Qmax and PSA (p=0.011 and p<0.001, respectively). Aquablation demonstrated significantly better preservation of ejaculation (p=0.002). Although transient incontinence was more frequent in HoLEP and gross hematuria and urinary retention were more common in Aquablation, none of the complication rates showed statistically significant differences.

Conclusions: Aquablation and HoLEP are both effective surgical options for BPH. Aquablation offers comparable symptom relief with significantly superior ejaculation preservation, making it particularly suitable for sexually active patients. HoLEP provides greater deobstructive efficacy, as evidenced by superior Qmax and PSA outcomes. These findings support individualized, patient-centered decision-making.