Purpose of Review <p>Underwater Endoscopic Submucosal Dissection (U-ESD) is a novel technique used to overcome the limitations of conventional ESD, particularly for gravity-side and fibrotic gastrointestinal lesions. This review aims to highlight the recent advancements in U-ESD, emphasizing its practical advantages as well as challenges that should be addressed for future applications.</p> Recent Findings <p>Due to the buoyancy effect created by saline, U-ESD provides natural traction as well as magnification to facilitate en bloc lesion resection without the need for additional traction devices. Recent findings, including “bubble-free” U-ESD techniques have addressed previous concerns by minimizing trapped air bubbles and visual obstruction to further advance the U-ESD method.</p> Summary <p>U-ESD offers an effective and safe method for the removal of complex gastrointestinal lesions through enhanced visualization and natural traction. Although challenges such as bleeding control remain, with ongoing refinements in the technique, U-ESD may become the standard in advanced therapeutic endoscopy.</p>