Image-Guided Robotic-Assisted Waterjet Ablation of Prostate (Aquablation) Versus Convective Water Vapor Thermal Therapy (Rezūm) in Patients with Prostate Volume Less than 80 Grams

Abstract

Purpose:

Aquablation and Rezūm are established minimally invasive surgical therapies for benign prostatic hyperplasia (BPH) in men with moderate-sized prostates. However, direct real-world data comparing outcomes of these techniques in prostates <80 g remain limited. This study aimed to evaluate and contextualize perioperative and functional outcomes of Aquablation and Rezūm in a prospective, nonrandomized cohort.

Methods:

We conducted a prospective, nonrandomized comparative cohort study between 2023 and 2025 at a single tertiary center. Treatment allocation was based on the patient’s informed preference following standardized counseling. Men with moderate-to-severe lower urinary tract symptoms and prostate volume <80 g were included. Outcomes included the International Prostate Symptom Score, quality of life (QoL), irritative symptoms, urinary continence, sexual function, perioperative parameters, complications, and retreatment. Between-group comparisons were exploratory and interpreted descriptively due to baseline differences.

Results:

A total of 428 patients were analyzed, including 324 who underwent Aquablation and 104 who underwent Rezūm. Baseline characteristics differed between groups, with Aquablation patients being older and having larger prostates and higher comorbidity burden. Both procedures resulted in significant and durable improvements in lower urinary tract symptoms and QoL. Aquablation demonstrated numerically greater symptom improvement and faster reduction in irritative symptoms, while Rezūm was associated with shorter operative time and same-day discharge. Erectile and ejaculatory function were largely preserved in both cohorts. Perioperative complication and retreatment rates were low and comparable.

Conclusion:

In this real-world, nonrandomized cohort, both Aquablation and Rezūm provided meaningful and durable symptom relief with preservation of sexual function in men with prostates <80 g. Given baseline imbalances and patient-preference-based allocation, outcomes should be interpreted as descriptive of real-world performance rather than as definitive comparative superiority. These findings support both modalities as effective minimally invasive options, with treatment selection guided by patient characteristics, expectations, and resource considerations.

Keywords

Rezūm Aquablation benign prostatic hyperplasia bladder outlet obstruction

Introduction

Benign prostatic hyperplasia (BPH) is one of the most common urologic conditions in aging men, with a prevalence approaching 70% in the seventh decade and nearly 80% beyond 70 years.¹ Progression to moderate or severe lower urinary tract symptoms (LUTS) significantly impairs quality of life (QoL) and can lead to urinary retention, recurrent urinary tract infections, and renal dysfunction.^2,3

Transurethral resection of the prostate (TURP) remains the gold standard for prostates weighing 30-80 g.⁴ Still, its associated morbidity, including bleeding, urethral stricture, and sexual dysfunction, has driven the development of minimally invasive surgical therapies (MISTs).⁵

Among these, Rezūm (convective water vapor thermal therapy) and Aquablation (image-guided robotic-assisted waterjet ablation) are increasingly adopted. Both provide durable symptom relief while preserving sexual function and allowing faster recovery.⁶ Recent long-term data support the sustained effectiveness of both interventions. Rezūm has demonstrated durable improvements in obstruction symptoms, International Prostate Symptom Score (IPSS), flow rate, and post-void residual after a single treatment.^7,8 Similarly, Aquablation has demonstrated durable 5-year outcomes in IPSS, uroflowmetry, and reintervention rates, with reduced ejaculatory dysfunction compared with TURP, especially in larger prostates.⁹ Current guidelines from the American Urological Association (AUA), Canadian Urology Association, and European Urology Association endorse Aquablation for prostate volumes of 30–80 cc, while Rezūm is recommended for small-to-moderate glands (typically <80 cc) as a minimally invasive alternative for appropriately selected patients.^10,11

However, despite increasing clinical use of both techniques, direct head-to-head comparison data in men with prostates <80 g remain limited. Most published studies have assessed each modality separately, often in diverse or larger cohorts, creating uncertainty about their relative effectiveness, safety, and durability in moderate-sized glands.¹²

This study aims to compare Rezūm and Aquablation in men with prostate volumes <80 g, evaluating their relative efficacy, safety, and durability.

Materials and Methods

This prospective, nonrandomized comparative cohort study was conducted between 2023 and 2025 and included men treated for BPH with prostate volume <80 g at a single tertiary medical center. Participants were divided into two groups: group A, patients who underwent Aquablation (n = 324), and group B, those who underwent Rezūm (n = 104). Eligible participants were men presenting with moderate to severe LUTS, as defined by the IPSS, or those who failed to achieve adequate relief with pharmacological therapy. Patients whose LUTS were not attributable to prostatic enlargement or who had other causes of bladder outlet obstruction (e.g., urethral stricture, neurogenic bladder) were excluded from the study. The study was approved by the Institutional Review Board (Helsinki Committee) of Shaare Zedek Medical Center, Jerusalem, Israel (Approval No. 0058-25-SZMC). The requirement for informed consent was waived by the IRB due to the use of anonymized clinical data.

All patients were offered both surgical options following standardized counseling, with a detailed explanation of the operative technique, potential complications, the expected need for an indwelling catheter following intervention, and the possible need for resumption of medical therapy or reoperation during follow-up. Treatment allocation was based on informed patient preference, and after reviewing all information, each patient independently decided to proceed with one of the two surgical interventions.

All participants completed a standardized battery of validated questionnaires, including the IPSS, QoL index, irritative symptom subscore (IPSS questions 2–4), the Short Form International Consultation on Incontinence Questionnaire–Urinary Incontinence, the International Index of Erectile Function–Erectile Function domain (IIEF-EF), and the Male Sexual Health Questionnaire–Ejaculatory Dysfunction Short Form. These tools were used to comprehensively assess urinary symptoms, QoL, and sexual function.

Demographic and clinical data were collected, including age, baseline prostate volume, baseline symptom severity, use of BPH-related medications, and concomitant anticoagulant or antiplatelet therapy. Additional clinical variables included American Society of Anesthesiologists (ASA) classification, catheter dependence, and the presence of a median lobe. Perioperative outcomes included total operative time (defined as the interval from procedure initiation to catheter placement), procedure-related adverse events classified according to the Clavien–Dindo system, length of hospitalization, and the need for secondary interventions for bladder outlet obstruction.

Patients in the Aquablation group were followed at 3, 6, and 12 months postoperatively, with subsequent annual visits. Patients in the Rezūm group underwent a similar follow-up schedule, in accordance with institutional practice patterns.

Statistical analyses were performed using GraphPad Prism 9 for macOS (version 9.5.0). Continuous variables were expressed as means ± standard deviations, and categorical variables as frequencies and percentages. Between-group comparisons were made using the Student’s t-test or Mann–Whitney U test for continuous variables and the χ² or Fisher’s exact test for categorical variables. Given the nonrandomized design and baseline differences between cohorts, between-group statistical comparisons were considered exploratory and interpreted descriptively. Changes over time were analyzed using repeated-measures analysis of variance or mixed-effects models, as appropriate. A two-tailed P value < .05 was considered statistically significant.

Results

A total of 428 patients were analyzed, including 324 who underwent Aquablation and 104 who underwent Rezūm. All procedures were performed at a single tertiary center. Given the nonrandomized design and patient preference-based allocation, baseline differences between cohorts were anticipated and are reported descriptively.

Baseline characteristics are summarized in Table 1. Patients treated with Aquablation were older than those undergoing Rezūm (70.5 ± 8.5 versus 64.9 ± 7.6 years) and had significantly larger prostates (60.6 ± 13.3 g versus 42.8 ± 12.8 g; P < .001). The median lobe prevalence was comparable between groups (37.0% versus 35.5%). Pre-procedure indwelling catheterization was more frequent in the Aquablation cohort (18.2% versus 0%; P < .001), as was prior prostate surgery (3.4% versus 0%; P < .001). Use of antithrombotic therapy (44.1% versus 21.0%; P = .001), baseline BPH medication (87.2% versus 97.0%; P = .002), and higher ASA classification were also more common among Aquablation patients, reflecting greater baseline clinical complexity.

Table 1.

Baseline Patient Characteristics

	Aquablation(n = 324)	Rezūm(n = 104)	P value
Age ± SD, years	70.5 ± 8.5	64.9 ± 7.6	.671
Prostate volume (±SD), cm³	60.6 ± 13.3	42.8 ± 12.8	<.001
Median lobe present, n (%)	120 (37.0%)	37 (35.5%)	.955
Pre-procedure indwelling catheterization n (%)	59 (18.2%)	0 (0%)	<.001
Prior prostate surgery n (%)	11 (3.4%)	0 (0%)	<.001
Antithrombotic use n (%)
Anticoagulation	39 (12.2%)	3 (2.8%)	.012
Antiplatelet	104 (31.9%)	19 (18.2%)	.018
Any of above	143 (44.1%)	22 (21%)	.001
BPH medication use n (%)
Alpha blocker	205 (63.2%)	86 (82.6%)	<.001
5-ARI	16 (4.9%)	1 (1%)	.085
Alpha blocker/5-ARI	62 (19.1%)	14 (13.4%)	.188
Any of above	283 (87.2%)	101 (97%)	.002

Perioperative parameters are presented in Table 2. The mean operative time was significantly longer for Aquablation compared with Rezūm (36.2 ± 12.6 versus 10.8 ± 4.7 minutes; P = .002). Hospitalization length following Aquablation averaged 2.09 ± 0.8 days, reflecting institutional postoperative observation policy, whereas Rezūm was routinely performed as a same-day procedure (P < .001).

Table 2.

Perioperative Data

	Aquablation(n = 324)	Rezūm(n = 104)	P value
ASA score
Grade I	5 (1.5%)	7 (6.7%)	.018
Grade II	232 (71.6%)	85 (81.7%)	.049
Grade III	85 (26.2%)	12 (11.5%)	.003
Grade IV	2 (0.6%)	0 (0 %)	.56
Operative time (handpiece in to catheter in), min	36.2 ± 12.6	10.8 ± 4.7	.002
Hospitalization length, days	2.09 ± 0.8	0	<.000

Functional outcomes are detailed in Table 3. Both treatment modalities resulted in marked and durable improvements in LUTS and QoL compared with baseline. In the Aquablation cohort, mean IPSS decreased from 24.5 ± 6.0 at baseline to 7.1 ± 5.4 at first follow-up and 6.2 ± 5.0 at final follow-up, whereas in the Rezūm cohort, IPSS improved from 16.1 ± 6.9 to 10.7 ± 6.5 and 10.6 ± 8.9, respectively. Between-group differences favored Aquablation numerically at all follow-up time points, though these comparisons should be interpreted cautiously due to baseline imbalance.

Table 3.

Functional Outcomes

Parameter	Timepoint	Aquablation (n = 324),Mean ± SD	Rezūm (n = 104),Mean ± SD	P value
IPSS	Baseline	24.5 (±6)	16.1 (±6.9)	<.001
	1^st Follow-up	7.1 (±5.4)	10.7 (±6.5)	.002
	2^nd Follow-up	5.6 (±5.9)	8 (±5.5)	.01
	3^rd Follow-up	6.2 (±5)	10.6 (8.9)	.004
IPSS QoL	Baseline	5.3 (±1.2)	4.7 (±2.7)	.03
	1^st Follow-up	1.3 (±1.4)	2.3 (±1.8)	.001
	2^nd Follow-up	1.4 (±2.8)	1.7 (±1.8)	.41
	3^rd Follow-up	1.1 (±1.5)	2.1 (±2.2)	.002
Irritative Score	Baseline	10.3 (±3.6)	9.6 (±7.6)	.37
	1^st Follow-up	3.4 (±4)	5.1 (±3.6)	.004
	2^nd Follow-up	2.5 (±3.5)	3.5 (±2.9)	.03
	3^rd Follow-up	3.7 (±5.1)	4.1 (±4.4)	.59
VAS Score	Baseline	0	0
	1^st Follow-up	0.47 (±1.9)	1.2 (±1.9)	.009
	2^nd Follow-up	0.42 (±2)	0.9 (±2)	.08
	3^rd Follow-up	0.15 (±0.4)	1.1 (±2.1)	<.001
SF-ICIQ Score	Baseline	14.5 (±5)	9.7 (±2.2)	<.001
	1^st Follow- up	11.9 (±4.4)	16.3 (±1.3)	<.001
	2^nd Follow-up	13.2 (±3.9)	12.2 (±5.7)	.10
	3^rd Follow-up	9.5 (±6)	8.8 (±4.1)	.18
EF-IIEF	Baseline	20.1 (±9.2)	21.4 (±7)	.130
	1^st Follow-up	18.7 (±9.4)	20.4 (±7.9)	.070
	2^nd Follow-up	17.7 (±10.8)	21.6 (±7.6)	<.001
	3^rd Follow-up	17.5 (±11)	20.6 (±8.6)	.003
MSHQ-EjD	Baseline	10.4 (±4.8)	9.5 (±5.8)	.154
	1^st Follow-up	7.3 (±5.8)	8.2 (±5.5)	.154
	2^nd Follow-up	6.7 (±5.1)	8.2 (±5.3)	.0.12
	3^rd Follow-up	6.7 (±6.4)	8 (±5.3)	.040
MSHQ-bother score	Baseline	1.1 (±1.6)	0.8 (±1.6)	.098
	1^st Follow-up	2.2 (±2.4)	1.6 (±1.9)	.009
	2^nd Follow-up	2.1 (±2.1)	1.7 (±1.9)	.070
	3^rd Follow-up	1.9 (±2.8)	2 (±1.9)	.681

QoL scores improved significantly in both cohorts, from 5.3 ± 1.2 to 1.1 ± 1.5 following Aquablation and from 4.7 ± 2.7 to 2.1 ± 2.2 following Rezūm. Irritative symptom subscores declined from 10.3 ± 3.6 to 3.7 ± 5.1 after Aquablation and from 9.6 ± 7.6 to 4.1 ± 4.4 after Rezūm. Dysuria VAS scores improved earlier after Aquablation (0.47 ± 1.9 at first follow-up) compared with Rezūm (1.2 ± 1.9), with convergence at later time points.

Urinary continence outcomes assessed by SF-ICIQ demonstrated improvement in both cohorts. Aquablation patients showed a reduction from 14.5 ± 5.0 at baseline to 9.5 ± 6.0 at final follow-up, while Rezūm patients improved from 9.7 ± 2.2 to 8.8 ± 4.1.

Sexual function outcomes remained largely preserved (Table 3). IIEF-EF scores remained stable in both groups, with Aquablation scores changing from 20.1 ± 9.2 to 17.5 ± 11.0 and Rezūm scores from 21.4 ± 7.0 to 20.6 ± 8.6 at final follow-up. MSHQ-EjD scores declined modestly in both cohorts, reaching 6.7 ± 6.4 after Aquablation and 8.0 ± 5.3 after Rezūm. Preservation of antegrade ejaculation was achieved in 84.2% of Aquablation patients and 88.5% of Rezūm patients, and these findings are reported descriptively.

Postoperative complications and retreatment rates are summarized in Table 4. Overall complication rates were low. Clavien–Dindo grade I–III events occurred in 17.7% of Aquablation patients and 10.5% of Rezūm patients, with a single grade IV complication (0.3%) in the Aquablation cohort. Re-initiation of medical therapy occurred in 2.4% after Aquablation and 6.7% after Rezūm, while surgical re-intervention rates were similar (3.0% versus 3.8%).

Table 4.

Postoperative Complications and Re-Intervention

	Aquablation(n = 324)	Rezūm(n = 104)	P value
Clavien–Dindo, n (%)
Grade I	22 (6.7%)	5 (4.8%)	.78
Grade II	28 (8.6%)	6 (5.7%)	.41
Grade III	8 (2.4%)	0	.21
Grade IV	1 (0.3%)	0	1
Re-intervention
Medication	8 (2.4%)	7 (6.7%)	.06
Surgical	10 (3%)	4 (3.8%)	.75

Discussion

AUA guidelines on BPH recommend considering Aquablation and Rezūm as surgical options for patients with bothersome LUTS and prostate sizes between 30 to 80 g.¹³ TURP has long been considered the gold standard for the treatment of symptomatic BPH,⁴ however, the possibility of serious complications following TURP, such as incontinence, bleeding, bladder neck contracture, and urethral stricture, as well as its impact on sexual and ejaculatory dysfunction, has been well documented and has driven the development of MISTs.⁵

Recent reports have emphasized that preservation of ejaculatory function remains a key determinant in patients’ surgical decision-making, with nearly half of men with BPH expressing concern about potential sexual dysfunction.¹⁴ Although Rezūm offers a favorable safety profile with a high rate of ejaculatory preservation, long-term randomized and real-world studies have demonstrated durable symptom relief with retreatment rates below 10% within 2–5 years post-procedure.¹⁵

Achieving an optimal balance between effective symptom relief and minimizing complications or negative impact on QoL remains a central challenge in BPH surgery. In the present nonrandomized cohort, patients undergoing Aquablation demonstrated numerically greater improvements in IPSS than those treated with Rezūm; however, these differences should be interpreted cautiously given significant baseline imbalances and patient preference-based treatment allocation. Accordingly, the current findings should not be interpreted as definitive evidence of the superiority of one technique over the other.

With respect to sexual outcomes, no clinically meaningful differences in erectile or ejaculatory dysfunction were observed between treatment groups. Preservation of antegrade ejaculation was high in both cohorts, and ejaculatory outcomes are therefore reported descriptively. Notably, Rezūm patients in this study demonstrated ejaculatory preservation rates comparable to those observed after Aquablation. This may be partly explained by routine treatment of the median lobe during Rezūm procedures at our institution, performed to optimize durable de-obstruction. These findings highlight the importance of preoperative counseling regarding the trade-off between maximal anatomical relief and the potential impact on ejaculatory function, allowing patients to make informed, individualized treatment decisions.

While Aquablation was associated with greater symptom improvement, it was also linked to a higher perioperative resource utilization and a small but relevant risk of bleeding-related complications. In prior work from our group, 3.1% of Aquablation patients experienced Clavien–Dindo grade III complications, predominantly due to significant hemorrhage requiring return to the operating room for surgical hemostasis.¹⁶ Although meticulous bladder neck fulguration is routinely performed following waterjet ablation, as previously recommended,¹⁵ bleeding may originate from aberrant vessels within the prostatic utricle, where conventional fulguration may be insufficient, as we have previously demonstrated.¹⁷ Awareness of this mechanism is essential, and early selective embolization should be considered when indicated.

Permanent urinary incontinence following BPH surgery is another serious complication with substantial impact on QoL. Previously reported series on Aquablation have demonstrated urinary incontinence rates of approximately 2%, while studies of Holmium Laser Enucleation of the Prostate, another ablative technique, have reported transient urinary incontinence in up to 15% of patients at 3 months postoperatively.¹⁸ In contrast, our data demonstrated excellent continence outcomes with both Aquablation and Rezūm. Using validated questionnaires, urinary continence was well preserved in both cohorts. Only a small and transient proportion of Aquablation patients reported mild urinary leakage in the early postoperative period, with complete resolution by 3 months, and no cases of stress or total urinary incontinence were observed in either group.

The favorable continence outcomes observed may be attributed to the nonthermal nature of both techniques and avoidance of excessive manipulation or stretching of the external sphincter. At our institution, alpha-blocker therapy is routinely prescribed for 1 month following Aquablation to mitigate postoperative irritative symptoms, a strategy previously shown to be beneficial in a randomized trial.¹⁹ Acute urinary retention following Rezūm has been reported in up to 8% of patients after initial catheter removal. In our practice, this risk has been mitigated by performing Rezūm under local anesthesia using ropivacaine with epinephrine, which reduces prostatic blood flow and tissue edema, shortens treatment time, and decreases energy consumption.²⁰ A randomized controlled trial is currently underway to further evaluate this anesthetic protocol.

This study is not without limitations. The nonrandomized design and patient preference-based allocation resulted in substantial baseline differences between cohorts, limiting the interpretability of unadjusted comparative analyses. In addition, follow-up duration was limited to approximately 30 months, precluding definitive conclusions regarding long-term retreatment rates. Nevertheless, the prospective design and structured follow-up enabled close monitoring of functional outcomes and early need for retreatment. By presenting real-world data from routine clinical practice, this study contributes meaningful information to shared decision-making for men considering MISTs for BPH.

Conclusions

Both Aquablation and Rezūm significantly improved lower urinary tract symptoms and QoL in men with prostates <80 g, while preserving erectile and ejaculatory function. Aquablation was associated with numerically greater and earlier symptom improvement but required longer operative time and greater perioperative resource utilization. Rezūm provided effective symptom relief with shorter recovery. Given the nonrandomized, patient-preference-based design, these findings should be interpreted descriptively. Both modalities are effective minimally invasive options, and procedure selection should be individualized.

Footnotes

Ethics Approval

This study was approved by the Institutional Review Board (Helsinki Committee) of Shaare Zedek Medical Center, Jerusalem, Israel (Approval No. 0058-25-SZMC). The requirement for informed consent was waived by the Institutional Review Board due to the use of anonymized clinical data.

Disclosure Statement

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this article.

Funding Information

No funds, grants, or other support were received.

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