WATER IV Prostate Cancer

Inclusion Criteria:

1. Biological male with age ≥ 45 years at the time of consent

2. Biopsy positive Grade Group 1-3 prostate cancer

3. Are candidates for prostatectomy or, in the case of GG1 disease, have alreadyselected a radical therapy as their treatment.

4. Clinical Stage ≤ T2c

5. PSA ≤ 20 ng/ml

6. Prostate volume ≥25 ml

Exclusion Criteria:

1. Any prior or current local or systemic treatment for prostate cancer, including butnot limited to surgery, radiation therapy (external or brachytherapy), tissueablation, hormone therapy or chemotherapy.

2. Patients with previous surgical or minimally invasive treatment of benign prostatichyperplasia within the prior 3 months of study treatment.

3. Evidence of lymph node, bone metastasis, extracapsular extension or seminal vesicleinvasion.

4. Patient is unwilling to accept a blood transfusion if required.

5. Any condition or history of illness or surgery that may pose an additional risk topatients undergoing the Aquablation or radical prostatectomy procedure such as:

5a. Medical conditions that preclude the use of anesthesia; 5b. Any condition or history of active rectal inflammatory bowel disease or other factors which might increase the risk of rectal injury (i.e. fistula formation); 5c. Patient is unable to stop anticoagulants or antiplatelet agents prior to study treatment per standard of care; 5d. Any other condition or history of infection, illness or surgery that in the opinion of the investigator might affect the outcome of the study procedure, study conduct, and study results; or pose additional risks to the patient (e.g., other cancer, active urethral stricture disease).

6. Patients who are unable to provide informed consent due to cognitive impairment, legal status (such as incarceration), or other factors limiting autonomy or unwilling or unable to follow study instructions including randomization and complete all required study visits through 10 years. This includes individuals with severe cognitive disabilities, those under legal guardianship, or those currently incarcerated.

7. Patient currently participating in other studies unless approved by Sponsor in writing.