Aquablation versus laser enucleation of the prostate for benign prostatic hyperplasia: a systematic review and pairwise meta-analysis of head-to-head studies including the first randomized trial

Background Holmium/thulium laser enucleation of the prostate (LEP) is an established, size-independent surgical option for benign prostatic hyperplasia, while Aquablation is an emerging robotic waterjet therapy. Until recently, the two had never been compared in a randomized head-to-head trial, and the only prior quantitative synthesis relied on an indirect, transurethral resection of the prostate (TURP)-anchored network comparison. We conducted the first pairwise meta-analysis restricted to studies directly comparing Aquablation and LEP, incorporating the first partially randomized head-to-head trial. Methods PubMed, Embase, Cochrane Library, and Scopus were searched for studies directly comparing Aquablation with HoLEP or thulium enucleation, following PRISMA 2020 and AMSTAR 2. The complete search strings for each database, the date of the final search, language and date restrictions, and the duplicate removal process. Outcomes were pooled using random-effects (DerSimonian–Laird) models as mean differences (MD) for continuous and risk ratios (RR) for dichotomous variables; outcomes exceeding I 2 of 95% were reported narratively rather than pooled. Prespecified subgroup analyses stratified studies by prostate volume, and a large propensity-matched claims database reporting 30- and 90-day safety outcomes was analyzed separately. Sensitivity analyses restricted to prospective studies and excluding higher-risk studies were performed to examine robustness. Results Of 126 records identified, 7 full-text articles were assessed for eligibility and 1 (ATHLETE) was excluded as a study protocol with no outcome data, leaving 6 studies: 1 partially randomized trial, 4 comparative cohorts ( n = 845 total), and 1 claims database (2,104 matched patients). Overall symptom relief did not differ significantly [International Prostate Symptom Score (IPSS) MD −0.93, 95% CI −2.13 to 0.27], though Aquablation showed a non-significant numerical trend in large glands (MD −1.21, 95% CI −2.51 to 0.08; exploratory subgroup, k = 2). Laser enucleation provided superior deobstruction, with higher maximum flow rate (Qmax MD −5.66 mL/s, −7.64 to −3.69), lower post-void residual (MD +11.96 mL), and greater tissue removal (residual prostate volume MD +23.4 mL). Aquablation markedly reduced ejaculatory dysfunction (RR 0.19, 0.11–0.32), an effect preserved across gland sizes. Operative time and hemoglobin drop showed extreme heterogeneity and were not pooled. Aquablation was associated with higher 30- and 90-day hospital readmission and catheter reinsertion rates in the claims database, but lower urinary tract infection at 90 days. Conclusions No statistically significant difference in overall symptom relief was observed between Aquablation and laser enucleation, though a non-significant numerical trend in large glands is exploratory and requires confirmation. Aquablation confers markedly better, size-independent ejaculatory preservation, while laser enucleation provides superior objective deobstruction. Certainty of evidence remains low to moderate given the limited partially randomized base and short follow-up. These findings support an individualized choice between procedures based on gland size and patient priorities. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD420261439112 , PROSPERO CRD420261439112.