Lessons from Richard Hindley’s first 100 cases
Few innovations in the surgical management of benign prostatic obstruction (BPO) have generated as much discussion as Aquablation (PROCEPT BioRobotics®). By combining robotically executed tissue resection with real-time transrectal ultrasound guidance, the technology promises something surgeons have long pursued: reproducible anatomical treatment with a favourable functional profile, particularly regarding preservation of ejaculatory function [1–4].
Early evidence has been encouraging, but as with any new technology, enthusiasm inevitably raises difficult questions. Where does Aquablation sit alongside TURP, GreenLight, HoLEP and the expanding range of minimally invasive surgical therapies (MIST)? Does it genuinely simplify surgery, or merely exchange one learning curve for another? And, most importantly, which patients stand to benefit the most?
Over three years and having undertaken multiple procedures, there has been ample opportunity to explore these questions in everyday practice. Rather than asking whether Aquablation replaces existing techniques, perhaps the more useful questions are: Where does it deliver the greatest benefit? What do surgeons need to learn? And how does it reshape the future of bladder outlet surgery?
When technology meets judgement
The operating theatre falls quiet as the treatment plan appears on the ultrasound screen. The prostate has been mapped, the boundaries defined, and within moments a robotically controlled waterjet will begin removing obstructing tissue with remarkable precision. To an observer, it might seem that the technology is in charge. However, the reality is somewhat different.
It is a deceptively simple observation, yet after more than 100 Aquablation procedures, it has become a defining lesson of our experience. Aquablation has attracted attention for its robotic execution and image-guided precision, however, its real significance lies elsewhere. The technology has changed how we plan surgery, how we select patients and, perhaps most importantly, what we think about the future of bladder outlet surgery itself.
"The robot only carries out the plan. The difficult part is creating the right one"
Questions about where Aquablation fits could never be answered by published trials alone. Over the past three years, the operating theatre lists have provided a far more practical education. Small refinements in technique, unexpected challenges in the earliest cases, and changing patterns of patient selection have gradually modified or adjusted our understanding of the procedure. Looking back, the first operations were less a milestone than part of the process of continuous adaptation, in which the surgeon evolved alongside the technology.
Looking for something better
Interestingly, the journey towards Aquablation did not begin with dissatisfaction. Quite the opposite. After almost two decades of GreenLight laser surgery and a decade offering MIST, (initially Urolift, but now Rezūm water vapour therapy and iTind), I had achieved excellent outcomes and felt entirely comfortable treating prostates of up to 150mL [1,5]. Yet increasing gland size brought an unavoidable trade-off: longer operating times, greater demands on theatre efficiency and a growing awareness that patient priorities were also changing. Increasingly, younger men were asking not only whether surgery would relieve their symptoms, but how it might adversely affect their quality of life afterwards.
The search for a better solution was therefore never about replacing one operation with another. It was about finding a technique capable of addressing a familiar clinical problem from a different perspective. Aquablation did not arrive to dethrone existing options; it expanded the surgical toolbox, particularly for larger prostates and for men wishing to preserve ejaculatory function. That distinction is fundamental. Modern BPO surgery is no longer about finding one superior operation but about matching the right procedure to the right patient. It will be a long time before we have the silver bullet for all BPO patients.
The first twenty cases If the first 100 cases taught me anything, it was that success in Aquablation depends not just on the technology itself but also the surgeon’s willingness to follow the latest recommendations to maximise the likelihood of a successful outcome, while also refining the technique when modifications are needed, as no two patients want or require the same thing. The learning curve was not defined by mastering the robot, but by recognising where judgement mattered most [5].
One of the earliest lessons centred on the bladder neck. Initial enthusiasm to maximise tissue removal occasionally resulted in unnecessary bleeding and more difficult visualisation during the final endoscopic phase. Experience gradually shifted this approach: a more conservative treatment plan around the bladder neck, followed by a systematic circumferential resection of the treated tissue, transformed haemostasis and made the remainder of the procedure considerably smoother.
Another important refinement was recognising residual anterior tissue, an area the waterjet will likely not always address adequately. Although the device removes tissue with remarkable precision, deciding when additional anterior resection is required remains a judgement only the surgeon can make. Returning to this tissue when appropriate reduces the likelihood of early retreatment. After approximately 20 procedures, we found the operation became less reactive and more anticipatory. Potential difficulties could be recognised and prevented before they developed, reinforcing an important principle: robotic precision still depends on thoughtful surgical planning.
The patient who changed my thinking
One consultation has remained particularly memorable. A 56-year-old man with a prostate approaching 100cc had several technically appropriate surgical options [5–8]. His greatest concern, however, was not urinary flow but it was preserving normal ejaculation. Although an enucleation procedure would have offered excellent anatomical relief, even a small perceived risk to functional outcomes was enough to shape his decision, and he was reluctant to proceed.
For this patient, Aquablation offered a balance between effective anatomical treatment and preservation of quality of life [3,6,7]. That consultation reinforced a lesson now central to my practice: there is rarely a universally “best” operation. Success depends on selecting the procedure that aligns with the patient’s anatomy, expectations and priorities, illustrating that the right procedure is defined not only by gland size but by what matters most to the man in front of you.
Training the next generation
Contrary to the perception that Aquablation simplifies bladder outlet surgery, the procedure demands a broader skill set, not a narrower one. It should not be viewed as a shortcut through BPO surgery. Although the robotic platform standardises part of the procedure, surgeons still require excellent endoscopic experience, confident interpretation of ultrasound anatomy, sound treatment planning and the ability to manage complications when they arise.
Robotics standardises execution, but does not replace the judgement required before, during or after the waterjet has finished its work. For units considering adoption, our message is straightforward: technology complements surgical judgement, and training programmes should be built around that principle rather than around the robot alone.
Patient selection
Perhaps nowhere is that judgement more evident than in patient selection. Over time, we have found the greatest benefit for men with larger prostates, particularly those with severe symptoms or urinary retention [4,5]. Equally important are younger patients who want durable symptom relief whilst preserving ejaculatory function and those men concerned about the possibility of short-term stress urinary incontinence.
Smaller glands may still be served by conventional TURP or other MIST techniques, whilst extremely large prostates may remain better suited to HoLEP in centres with that expertise [9,10]. The clearest message after 100 cases is not that Aquablation should replace what came before, but that it has earned a defined place within a broader, patient-led decision- making process increasingly shaped by comparative evidence rather than by enthusiasm alone.
Innovation without the hype
Looking beyond individual cases, we remain cautious about innovation for innovation’s sake. Experience makes us wary of technologies that promise more than they deliver. The measure of innovation is simple: does it improve outcomes that genuinely matter to patients? Can it be reproduced beyond expert centres? And can it be taught safely to future surgeons [6–10]?
“Novelty is easy. Genuine transformation is rare.”
Our conclusion is measured rather than evangelical. Aquablation has not eliminated the need for surgical judgement; instead, it has reinforced its importance. Robotics may execute the treatment plan, but only experience determines whether that plan is the right one.
The shift from monopolar to bipolar TURP has been slower than we would have hoped, but it is likely that with further adaptions and refinements to this technology that the ability of a robotically delivered high-pressure waterjet system will facilitate a more rapid change to what is arguably the potential replacement for TURP. This will be driven by more easily measured benefits, such as reduced procedure time and improved rates of same day discharge (compared with bipolar TURP) as well as the clear advantages of an improved side-effect profile. The requirement for MIST will remain and likely grow as long-term data for therapies such as Rezūm continue to accumulate; but a challenge to establish TURP practice alongside this robotically executed system is likely.
Looking ahead
The future of bladder outlet surgery is unlikely to belong to a single operation for a long time. Instead, it will be characterised by image guidance, robotics, artificial intelligence and increasingly personalised treatment selection [4,8]. Whatever technology emerges next, the conclusion is that the surgeon’s greatest responsibility remains unchanged: selecting the right patient, planning the right operation and adapting with experience. The skills required for the procedure itself will become less important as we move towards less complexity and greater reproducibility for the surgical treatment of this common condition.
References
1. Gilling P, Anderson P, Tan A. Aquablation of the Prostate for Symptomatic Benign Prostatic Hyperplasia: 1-Year Results. J Urol 2017;197(6):1565–72.
2. Gilling P, Barber N, Bidair M, et al. Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol 2022;29(1):10960–8.
3. Medtech innovation briefing. Aquablation robotic therapy for lower urinary tract symptoms caused by benign prostatic hyperplasia. NICE 2023.
www.nice.org.uk/advice/mib315
4. Cornu JN, Elterman D, Hashim H, et al. EAU Guidelines on Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS). EAU Guidelines Office, Arnhem, the Netherlands 2026.
https://uroweb.org/guidelines/management
-of-non-neurogenic-male-luts
5. Desai M, Bidair M, Zorn KC, et al. Aquablation for benign prostatic hyperplasia in large prostates (80-150 mL): 6-month results from the WATER II trial. BJU Int 2019;124(2):321–8.
6. Bhojani N, Bidair M, Kramolowsky E, et al. Aquablation Therapy in Large Prostates (80-150 mL) for Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: Final WATER II 5-Year Clinical Trial Results. J Urol 2023;210(1):143–53.
7. Pimentel MA, Yassaie O, Gilling P. Urodynamic Outcomes After Aquablation. Urology 2019;126:165–70.
8. Nguyen DD, Barber N, Bidair M, et al. Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30-80 and 80-150 mL prostates. BJU Int 2020;125(1):112–22.
9. Bhatia A, Titus R, Porto JG, et al. Comparing outcomes of Aquablation versus holmium laser enucleation of prostate in the treatment of benign prostatic hyperplasia: A network meta-analysis. BJUI Compass 2024;5(12):1231–45.
10. Justo Quintas J, García Rojo E, García Gómez B, et al. Aquablation vs. holmium laser enucleation of the prostate for benign prostatic hyperplasia: a 150-patients prospective comparative multicenter study. Minerva Urol Nephrol 2025;77(1):111–9.
[All links last accessed July–August 2026].
Declaration of competing interests: Richard Hindley received reimbursement as an expert proctor and adviser from Boston Scientific, PROCEPT BioRobotics® and Olympus.
