Enlarged prostate (BPH)
What the published trials say about symptom relief, durability, anesthesia, recovery and sexual side effects when comparing prostate artery embolization with Aquablation.
Editorially updated October 15, 2026. This educational article was prepared by SoCal Interventional using the cited primary and authoritative sources. It does not replace an individualized medical evaluation.
Quick answer: Prostate artery embolization (PAE) and Aquablation treat an enlarged prostate in opposite ways. Aquablation is an operating-room procedure in which a robot-guided water jet removes prostate tissue under anesthesia; in its randomized trial against TURP it produced a symptom-score drop of about 15 points that held at 5 years, with a low need for further treatment. PAE is an outpatient procedure performed through an artery with no instrument in the urethra; in randomized trials it improves symptoms meaningfully but by somewhat less than surgery, and more men need another treatment over the years. No trial has compared the two directly. Men with a large prostate who want tissue removed and accept anesthesia and a catheter lean toward Aquablation; men who want to avoid surgery, are on blood thinners, or have higher anesthesia risk lean toward PAE.
PAE is offered at our Fountain Valley office in Orange County as well as in Van Nuys and Tarzana. Aquablation is a urology procedure that we do not perform; this article is meant to help you ask better questions of both specialists.
Aquablation (robotic waterjet treatment). Under general or spinal anesthesia, a urologist maps the prostate with real-time ultrasound and a robotic high-pressure water jet removes the obstructing tissue along that map through the urethra. Tissue is physically removed, so the urinary channel is wider as soon as healing allows. A catheter is placed afterward and a hospital stay is usual.
Prostate artery embolization. An interventional radiologist threads a catheter from the wrist or groin into the small arteries that feed the prostate and injects microscopic particles that block them. With less blood supply the gland softens and shrinks over the following weeks. Nothing is passed through the urethra, sedation rather than general anesthesia is used, and most men go home the same day. Improvement is gradual, usually becoming noticeable over two to six weeks (see our PAE recovery timeline).
The two procedures have never been randomized against each other. Each has been tested against TURP, the traditional operation, so the fairest comparison is how each performed against that common benchmark. The numbers below come from different trials with different patients and should be read as context, not as a direct contest.
| Measure | Aquablation (WATER trial vs TURP) | PAE (Swiss trial vs TURP) |
|---|---|---|
| Trial | Gilling et al., Can J Urol 2022: 181 men, prostates 30–80 mL, 116 Aquablation vs 65 TURP, 5-year follow-up | Abt et al., BMJ 2018: 103 men, 51 PAE vs 52 TURP, primary outcome at 12 weeks |
| Symptom score (IPSS) improvement | 15.1 points at 5 years vs 13.2 after TURP (difference not statistically significant) | 9.23 points at 12 weeks vs 10.77 after TURP; difference 1.54 points in favor of TURP (95% CI −1.45 to 4.52); non-inferiority of PAE not shown |
| Peak urinary flow (Qmax) | +8.7 mL/s at 5 years vs +6.3 after TURP | +5.19 mL/s vs +15.34 after TURP |
| Need for further BPH treatment | 6.0% (7 of 116) at 5 years vs 12.3% (8 of 65) after TURP | Not a 12-week endpoint; see the durability section below |
| Anesthesia and stay | General or spinal; mean hospital stay 1.4 days in both arms | Moderate sedation; 2.2 days vs 4.2 days after TURP under a protocol that admitted every patient (same-day discharge is typical in outpatient practice) |
| Ejaculation | Procedure-related loss of ejaculation at 3 months 7% vs 25% after TURP | Some ejaculatory dysfunction in 56% (14 of 25 assessed) vs 84% (21 of 25) after TURP |
| Adverse events | Primary safety endpoint at 3 months 26% vs 42% after TURP; one transfusion during the procedure in the Aquablation arm, none after TURP | 36 treatment-related events after PAE vs 70 after TURP (P=0.003) |
Two further points sharpen the picture. In the WATER trial, men with prostates of 50 mL or more had about 3.5 points more symptom improvement with Aquablation than with TURP across follow-up, which is why Aquablation is often favored for larger glands. In the Swiss trial, PAE shrank the prostate by about 12 mL on MRI against 30 mL after TURP and reduced residual urine less, which is consistent with embolization being a gentler, slower-acting treatment.
For a large prostate, both procedures are options with different trade-offs. Aquablation has 5-year data in 80 to 150 mL glands (WATER II) showing a large, durable improvement at the cost of anesthesia, a catheter and a hospital stay; PAE has no upper size limit and is less invasive, but roughly one man in five needs another treatment by 5 years.
Aquablation was studied separately in very large glands. The WATER II trial enrolled men with prostates of 80 to 150 mL (mean 107 mL). At 5 years the mean symptom score had fallen from 22.6 to 6.8, peak flow had roughly doubled from 8.6 to 17.1 mL/s, and 96.3% of men were free of a second BPH procedure. That is strong durability for a size range in which office procedures such as UroLift and Rezum are generally not offered.
PAE has no upper size limit and large glands are one of the most common reasons men are referred for it, often after being told that the office procedures are not an option. Our long-term review, how long does PAE last, summarizes the largest published series (1,072 men followed for an average of about 4.4 years): symptom scores stayed improved for most men, but roughly one in five needed another treatment by 5 years and more than half by 10 years. For a man with a 100 mL prostate, then, the realistic framing is this: Aquablation offers a larger, more durable average result at the cost of anesthesia, a catheter and a hospital stay; PAE offers a less invasive path with a real chance of needing something more later.
The AUA guideline treats both as conditional options, not first choices: robotic waterjet treatment may be offered for prostates of 30 to 80 g, and PAE may be offered when performed by clinicians trained in the procedure after a discussion of risks and benefits (both Conditional recommendations, Evidence Level Grade C). The decision is meant to be shared.
The American Urological Association guideline on lower urinary tract symptoms attributed to BPH (2023 amendment) treats both as options rather than first choices. It states that robotic waterjet treatment may be offered to patients with LUTS/BPH with a prostate volume of 30 to 80 g (Conditional recommendation, Evidence Level Grade C), and that PAE may be offered for the treatment of LUTS/BPH, performed by clinicians trained in this interventional radiology procedure after a discussion of the potential risks and benefits (Conditional recommendation, Evidence Level Grade C). In plain terms, the guideline considers both reasonable for the right patient and expects the decision to be shared, not automatic.
Aquablation tends to suit men who want tissue physically removed and the most immediate improvement in flow, who are fit for general or spinal anesthesia, who accept a catheter and a short hospital stay, and whose prostate is medium to very large. It is also the tissue-removing option that best preserves ejaculation in the published data.
PAE tends to suit men who want to avoid surgery and a urethral instrument altogether, men on blood thinners or with heart or lung conditions that make anesthesia riskier, men with very large glands who are not surgical candidates, and men who accept a gradual, somewhat smaller average improvement in exchange for a same-day outpatient procedure. Our PAE candidacy page describes the evaluation, and the five-way comparison of PAE, UroLift, Rezum, Aquablation and TURP places both procedures alongside the office-based options.
Neither has been shown better in a head-to-head trial, because none exists. Aquablation removes prostate tissue in an operating room and, in its own trials, produced symptom-score improvements of about 15 to 16 points at 5 years with low retreatment. PAE shrinks the gland through its blood supply without anesthesia or a urethral instrument, with a somewhat smaller average improvement than surgery in randomized trials. Which is "better" depends on prostate size, surgical risk, and what a man wants to avoid.
Yes. PAE has no upper size limit, and large glands are among the most common reasons men are referred for it. Aquablation has also been studied in 80 to 150 mL prostates (the WATER II trial), so both remain options for a large prostate; the difference is invasiveness and the kind of recovery.
Both preserve ejaculation better than TURP in the published data. In the WATER trial, procedure-related loss of ejaculation at 3 months was 7% after Aquablation versus 25% after TURP. In the Swiss PAE versus TURP trial, 56% of the men assessed reported some ejaculatory change after PAE versus 84% after TURP, so PAE is not free of ejaculatory effects either and this should be part of the conversation before any procedure.
Aquablation is performed under general or spinal anesthesia with a catheter afterward; in the WATER trial the mean hospital stay was 1.4 days. PAE is done under moderate sedation through an artery in the wrist or groin, and most of our patients go home the same day; the Swiss trial, which admitted all patients by protocol, still reported a shorter stay after PAE (2.2 days) than after TURP (4.2 days).
A prior PAE does not prevent surgery. If symptoms persist or return, the options are the same as before: adjusting medication, a repeat embolization when the arteries can still be reached, or a tissue-removing procedure such as Aquablation, TURP or HoLEP. In the largest long-term PAE series, roughly one man in five needed another treatment by 5 years.
Aquablation is performed by a urologist in an operating room. PAE is performed by an interventional radiologist; the AUA guideline says it should be done by clinicians trained in this interventional radiology procedure. Many men see both specialists before deciding.
Call (310) 929-0026 or request a consultation. Orange County patients are seen at our Fountain Valley office, 10900 Warner Ave, Suite 101A, Fountain Valley, CA 92708; Los Angeles patients are seen in Van Nuys and Tarzana. Bring any prostate imaging, PSA results and your current medication list, and tell us if a urologist has already discussed Aquablation with you so the two options can be weighed together.
Medical disclaimer: This article provides general education and cannot tell an individual man which procedure is right for him. The figures above are averages from separate trials with different patients and were not measured head to head; your own candidacy, likely benefit and alternatives require an in-person evaluation.
Explore more: Read the complete prostate artery embolization treatment guide, PAE vs TURP, the PAE Patient Resource Center, and our Medical Editorial Policy.
Medical content reviewed by Nathanael Sabbah, MD, interventional radiologist. Last reviewed: October 2026.