I had the same question. Why not aquablation for Gleason 7 at least? Maybe not 8 and 9. I will explain. Apparently aquablation leaves some margin tissue behind. This makes it better for incontinence, it spares the involuntary bladder sphincter at the neck of the prostate, and for ED, it spares the nerve area. But at the same time, that unremoved tissue could grow back cancer. Also, there is some questions as to whether the treatment causes cancer cells to escape into the blood stream. Full RALP is better at this because it doesn't ablate the tissue and leave small bits to escape as it captures the whole organ and puts it in a bag and removes it. I think that's the purpose of the bag process. Simple removal and dragging the resected organ through the abdomen would leave some tissue behind. Procept, the maker of the aquablation equipment, is running studies throughout the US at different hospitals, using their machine to treat prostate cancer. I think some of those results are out but they are small studies and conclude no significantly greater long term cancer cell clusters remain days/months after aquablation treatment. But they funded those studies so its not clear how unbiased they are. Also, existing studies are considered significant if they have 10,15,20 year results such as the studies comparing radiation to RALP. So, Gleason 8 and up cancers are too risky to try a new treatment on . I think this is a viable alternative to RALP as is HOLEP for less aggressive cancers. Decipher score also important to note. More to come with time.