The core aquablation pentafecta: a five-domain composite definition of procedural success and learning curve validation in 300 consecutive cases

Aquablation, a robotic waterjet ablation guided by real-time ultrasound, is increasingly used for benign prostatic obstruction (BPO). Randomized and comparative studies demonstrate efficacy, safety, and superior functional preservation compared with thermal or laser techniques. We propose and validate a five-domain Core Aquablation Pentafecta integrating objective, functional, and safety endpoints to define comprehensive procedural success. Three hundred consecutive men underwent Aquablation (2019–2024). The five Core Pentafecta domains were: (1) ≥ 50% reduction or ≥ 10-point improvement in IPSS, (2) ≥ 50% increase in Qmax, (3) no Clavien–Dindo ≥ III complication or transfusion, (4) preservation of continence and antegrade ejaculation, and (5) freedom from retreatment ≤ 24 months. Sequential 50-case cohorts were analyzed for learning-curve effects. Median age 67 years; median prostate 72 mL (range 22–220). Median operative time 45 min. IPSS improved from 23.4 ± 6.1 to 7.1 ± 4.8 (p < 0.001); Qmax from 8.9 ± 3.2 to 20.3 ± 6.0 mL/s (p < 0.001). Major complications 4%, no transfusions. All patients continent; 88% preserved antegrade ejaculation. No retreatments within 24 months. Core Pentafecta achievement rose from 58% (first 50 cases) to 73% overall and 82% after 150 procedures. The Core Aquablation Pentafecta provides a concise, reproducible metric integrating efficacy, safety, and durability. Achievement improved markedly with experience, plateauing above 80%, and was associated with sustained functional outcomes, supporting Aquablation as a function-preserving and durable robotic therapy for BPO in routine clinical practice.