Safeguarding ejaculatory outcomes through novel technology and anatomy appreciation
Aquablation offers notable upfront benefits.
Over the past century, myriad surgical advancements have paved the way for personalized treatment approaches and a renewed focus on preserving male ejaculatory function. Maintaining ejaculatory function is a priority for most men opting for surgical therapy. Given the current availability of BPH treatment options that preserve ejaculation, it is imperative that men are counseled and offered a tailored therapy.
Over the past decade, the advent of minimally invasive surgical techniques (MIST) and robotic-assisted procedures, according to Kevin Zorn, MD, FRCSC, FACS, have provided urologists the opportunity to treat BPH LUTs effectively while preserving ejaculation. Dr. Zorn, a urologist and founder and director of BPH Canada Prostate Surgical Institute in Montreal, Canada, is a presenter at this Sunday’s Plenary session, “State-of-the-Art Lecture: Preservation of Ejaculatory Function with BPH Treatments,” 1:10-1:25 p.m. in the Venetian Ballroom. He will be joined by a panel of colleagues who will guide attendees through a historical and contemporary exploration of such advancements.
“In recent years, the emergence of MIST and robotic ultrasound-guided Aquablation has empowered urologists of varying expertise to safeguard ejaculatory outcomes—with published series reporting ejaculation dysfunction in 0% for Urolift and iTIND, 2% with OptilumeBPH, less than or equal to 3% for REZUM and less than 15% for Aquablation,” Dr. Zorn said. “These innovations have also reshaped our understanding of the key anatomic landmarks essential for sexual preservation.”
Aquablation is a minimally invasive, heat-free surgical procedure used to provide a tailored, personalized treatment for benign prostatic hyperplasia (BPH) or an enlarged prostate. It uses a robotic-guided, heat-free, high-pressure water jet to precisely remove excess prostate tissue, offering a promising alternative to traditional BPH surgeries. Through its unique, real-time, ultrasound imaging of the prostate, urologists have a greater understanding of the importance of the apical tissue surrounding the verumontanum. As noted in the recent WATER III clinical trial, compared to HOLEP, the deliberate preservation of such apical tissue provided men with large prostates superior ejaculation rates (85% versus 23%) as well as better stress incontinence rates at three months (0% versus 9.1%).
Traditionally, surgical dogma emphasized bladder neck closure to preserve male ejaculatory function, Dr. Zorn said. However, current perspectives and recent pelvic imaging research during ejaculation have shifted toward the importance of conserving the pericollicular tissue surrounding the verumontanum. Anatomic studies have demonstrated that the ejaculatory ducts can be preserved with approximately 90% accuracy when a block of tissue 7.5 mm from the midline on either side of the verumontaum is preserved, coupled with up to 10 mm proximal to the verumontanum during transurethral resection of the prostate (TURP).
For the first time since the historical first BPH surgery (retropubic prostatectomy over a century ago), robotic Aquablation provides image guidance, precise artificial intelligence (AI)-assisted treatment mapping and monitoring, ultimately enabling anatomic selective apical sparing therapy. The butterfly apical cut significantly contributes to Aquablation’s favorable safety and efficacy profile, resulting in lower rates of ejaculatory dysfunction (less than or equal to 15%), significantly superior to traditional treatments such as TURP, laser enucleation and simple prostatectomy, with dysfunction rates greater than 60%.
However, in settings where robotic technology is unavailable, alternative approaches such as modified laser and TURP techniques—with intentional preservation of the same critical apical structures—have demonstrated promising results in maintaining ejaculatory function without compromising improvements in lower urinary tract symptoms (LUTS), Dr. Zorn said.
“For patients, Aquablation offers notable upfront benefits, including sustained improvements in lower urinary tract symptoms (LUTS), enhanced urinary flow, and reduced post-void residual (PVR), with efficacy maintained up to five years and low retreatment rates,” he said. “Importantly, outcomes from the randomized trials WATER and WATER III demonstrate comparability to TURP and HoLEP, but with the added advantage of superior preservation of sexual function and lower incidence of stress urinary incontinence.”
Although procedural risks include potential bleeding, hematuria and the need for transfusion, Dr. Zorn said that advances in surgical technique and energy delivery have reduced transfusion rates to below 0.5%, all while treating a variety of prostate sizes. From the surgeon’s standpoint, he added, the robotic platform facilitates standardized, reproducible procedures with operative times typically under one hour, regardless of prostate size.
“The streamlined learning curve and procedural efficiency have enabled urologists to increase patient throughput and manage larger prostates that would otherwise necessitate referral for simple prostatectomy or laser enucleation,” Dr. Zorn said. “The Aquablation procedure is automated and highly programmable. As such, it offers significant ergonomic advantages for surgeons by minimizing physical strain and reducing procedural complexity, leading to lower cognitive and physical stress compared to the demanding manual resection techniques required in TURP and HoLEP.”
Thanks to Aquablation, similar principles of anatomic preservation have begun to influence other techniques such as HOLEP, ThULEP and TURP, where a “butterfly preservation” approach is being explored to enhance ejaculatory outcomes, he said.
“This is particularly important for the 90% of countries globally (176 out of 195), where Aquablation technology is not yet available, reinforcing the need for refined techniques using existing modalities,” Dr. Zorn said. “More broadly, our evolving understanding—driven by an aging yet sexually active population—highlights the critical need for urologists to engage in open conversations with patients about sexual function and ejaculation preservation.”
Dr. Zorn reminds urologists that personalized treatment planning should account for prostate size, patient age, comorbidities and individual values, underscoring the importance of shared decision-making in modern BPH management. Additionally, as a community, urologists must continue to gather longer-term data on apical ejaculatory preservation strategies to better understand their impact on treatment durability.
“As we advance toward achieving the ideal BPH treatment trifecta—maximizing LUTS relief and durability while preserving urinary continence and sexual function—it becomes more apparent that we need to enhance intraoperative visualization of the ejaculatory duct system to prevent inadvertent injury. You cannot protect what you cannot see,” he said.
As such, the management of BPH has evolved into a more complex, patient-centered endeavor, where preserving ejaculatory function is as critical as relieving urinary symptoms. From MISTs like UroLift and Rezum, and advanced surgical techniques like ejaculatory hood-sparing and Aquablation, urologists have a diverse toolkit to meet patients’ needs.
“By combining precise integrating anatomical techniques precision, cutting-edge imaging technologies, innovative imaging and meaningful patient dialogue, the field is actively redefining what high-quality, holistic care looks like. With ongoing research and additional technologies moving to market, the future holds even greater promise for helping men with BPH preserve not only their urinary function, but also their sexual health,” Dr. Zorn said.
