How to Prevent Complications During Aquablation. Lessons Learned from a Prospective Series

OBJECTIVE: To evaluate perioperative complications following robotic water-jet ablation (Aquablation) for benign prostatic hyperplasia and to identify modifiable intraoperative technical factors associated with adverse events. MATERIALS AND METHODS: This prospective single-center study included 628 consecutive patients who underwent Aquablation between March 2023 and December 2025. Perioperative outcomes, postoperative complications, functional results, and delayed reinterventions were recorded prospectively. Adverse events were graded using the Clavien-Dindo classification. Technical factors associated with complications were analyzed using a structured review of intraoperative findings and postoperative outcomes. Early complications were mostly low-grade. Bleeding-related events included transfusion in 52 patients (8.2%), clot retention in 19 (3.0%), endoscopic fulguration in 8 (1.3%), and angioembolization in 2 (0.3%). A temporal analysis demonstrated a marked reduction in transfusion rates following stepwise technical refinements, decreasing from approximately 8% in the initial phase to 1% in later cases. Urinary retention occurred in 32 patients (5.1%), of whom 4 (0.6%) required suprapubic catheter placement. Delayed reintervention was required in 34 patients (5.4%), most commonly transurethral resection of the prostate (4.6%). Intraoperative factors associated with complications included bladder-neck jet misalignment (bleeding), inadequate apical resection (retention), traumatic handpiece insertion (urethral complications), and overlapping distal resection planes causing delayed obstruction ("cross-healing"). CONCLUSIONS: Aquablation provides significant and durable symptom improvement with an acceptable safety profile in real-world practice. Outcomes appear highly reproducible, whereas many complications are related to modifiable technical factors. Optimization of surgical technique may improve procedural safety and long-term durability.