Complication Profile and Safety Outcomes of Aquablation in the Management of BPH

Background and Objectives: Aquablation, a robot-assisted, heat-free resection technique, has emerged as a promising minimally invasive surgical therapy (MIST) for benign prostatic hyperplasia (BPH). Its precision and potential for preservation of sexual function distinguish it from traditional surgical options. This systematic review aimed to evaluate the safety profile of Aquablation, with emphasis on perioperative complications and functional outcomes. Materials and Methods: We systematically searched PubMed/MEDLINE, Scopus, and the Cochrane Library through June 2025 in accordance with PRISMA 2020 guidelines (PROSPERO CRD420251074479). Eligible studies included randomized and non-randomized trials of Aquablation in men with BPH, reporting adverse events by type, frequency, or severity. Risk of bias was assessed with ROB-2 and ROBINS-I tools. Results: Forty-seven studies were included, spanning randomized controlled and prospective observational designs. Most complications were minor (Clavien-Dindo grade 1-2). Bleeding was the most frequent perioperative event, with transfusion required in 1-8% of cases, more often in large prostates. Severe complications (grade ≥ 3) were uncommon and usually related to bleeding or urinary retention. Long-term sequelae such as strictures or bladder neck contracture were rare. Compared with transurethral resection of the prostate, Aquablation yielded lower rates of ejaculatory dysfunction (10% vs. 36%), with continence and erectile function largely preserved. Outcomes were comparable to holmium laser enucleation, but Aquablation demonstrated superior ejaculatory preservation. Conclusions: Aquablation demonstrates a favorable safety profile across prostate sizes, with its greatest advantage being preservation of sexual function. While bleeding remains the principal perioperative concern, life-threatening events are rare. Further independent, long-term comparative studies are warranted.