Aquablation versus AEEP for BPH: technique, outcomes, and the evolving surgical landscape - an EAU endourology perspective.

PURPOSE: To compare Aquablation and anatomical endoscopic enucleation of the prostate (AEEP) for the surgical management of benign prostatic hyperplasia (BPH), focusing on surgical technique, perioperative outcomes, functional results, safety, and durability. METHODS: A narrative review of randomized controlled trials, prospective studies, and real-world evidence was performed, including key studies such as WATER I, II, and III, as well as large-gland cohorts and guideline-based data evaluating Aquablation and AEEP. RESULTS: Both Aquablation and AEEP provide significant and durable improvements in lower urinary tract symptoms and urinary flow across a wide range of prostate sizes. AEEP remains the reference standard for size-independent treatment, with long-term retreatment rates of approximately 1-2%, but is associated with a steep learning curve and high rates of ejaculatory dysfunction. Aquablation offers a standardized, image-guided, heat-free approach with a shorter learning curve and higher rates of ejaculatory function preservation. Randomized evidence, including WATER III, demonstrates comparable short-term symptom relief and safety outcomes between Aquablation and laser enucleation in prostates up to 180 mL. Aquablation shows slightly higher retreatment rates (approximately 3-8% at 5 years) but maintains favorable functional outcomes. CONCLUSIONS: Aquablation and AEEP are effective and complementary surgical options for BPH. AEEP provides superior long-term durability, whereas Aquablation offers improved functional preservation and procedural standardization. Treatment selection should be individualized based on prostate characteristics, surgeon expertise, and patient priorities.