Naeem Bhojani, MD, expands on key findings from WATER III trial

Three-month data from the WATER III trial (NCT04801381) were recently shared during the 40th Annual European Association of Urology Congress in Madrid, Spain. In the trial, Aquablation demonstrated non-inferiority to transurethral laser enucleation of large prostates (LEP) regarding the study’s primary end point of mean change in International Prostate Symptom Score (IPSS).¹ Specifically, the change in IPSS from baseline to 3 months was 12.9 in the Aquablation arm vs 13.1 in the LEP arm (mean delta, 0.86; 95% CI, -1.6 to 3.2; P = .745).

Patients in the Aquablation arm also demonstrated lower rates of ejaculatory dysfunction and urinary incontinence following surgery. Specifically, ejaculatory dysfunction within 3 months following surgery was reported in 14.8% of patients in the Aquablation arm vs 77.1% of patients in the LEP arm (P < .0001). Further, 8.7% of patients in the Aquablation arm reported incontinence persistent to 3 months compared with 20.0% of patients who underwent LEP (P = .0690).

In the following interview, Naeem Bhojani, MD, FRCSC, expands on each of these key findings. Bhojani is a professor of urology at the University of Montreal, Quebec, Canada.

On the non-inferior IPSS findings, Bhojani predicts that results will be similar out to 5 years based on data from the previous WATER I and WATER II trials. However, he says that there isn’t much data after 5-year follow-up for Aquablation, making those outcomes unknown. For enucleation, data has shown that IPSS reduction is maintained out to 20 years.

Bhojani also noted that the finding of lower rates of retrograde ejactulation with Aquablation has important implications for patient counseling.

“I think it will help patients decide what prostate surgery they want,” Bhojani explained. “If ejaculation is something that patients really want and they want to maintain it, then I think they're going to have to choose Aquablation, because with enucleation, we know they will lose their ejaculation.”

The risk of early incontinence also has important implications for patient counseling.

“Now, if you go out 1 year, incontinence is pretty much the same with any BPH surgery,” said Bhojani. “But the early incontinence in prostate enucleation is, as this shows, about 20% to 30%, and there are patients who really don't want that risk. If a patient tells me, “Listen, I don't want a risk of incontinence, even if it's only temporary,” then I try to explain to them that maybe Aquablation is a better option for them.”

REFERENCE

1. Ritter M, Stein J, Barber N, et al. WATER III: Aquablation vs. Transurethral laser enucleation of large prostates (80-180ml) in benign prostatic hyperplasia. Presented at 40th Annual European Association of Urology Congress. Madrid, Spain. March 21-24, 2025. Abstract GC4