How a Patient-Preference Survey Decides Its Own Answer

A methodological reading of a sponsor-funded BPH survey — and what the independent literature finds when it asks the harder question.

A 2020 survey of men facing or recovering from BPH surgery asked them, in writing, whether they would be willing to sacrifice sexual function for relief of their urinary symptoms. The question sits in the published instrument as item Q14 for men still considering surgery and as Q10S for men who had already had it. The paper that reported the survey never tells you how they answered. It reports instead that 95% of respondents considered maintaining erectile function important and 92% considered maintaining ejaculatory function important, and it builds its conclusion on those two numbers. The willingness-to-trade item was asked and dropped.

It is not a small omission, and the reason it is not small is the whole point.

A survey can choose its answer before anyone responds

When you ask a man whether maintaining erectile function matters to him, and you ask it on its own, you have not learned much. Endorsing a desirable thing in isolation costs the respondent nothing. There is no competing good on the table, no price to pay for saying yes. Under that format, near-universal agreement is the expected result for almost any attribute a person would, all else equal, prefer to keep. Ninety-five percent is not a finding about how much sexual function weighs in a surgical decision. It is a property of the question.

The way to learn what an attribute actually weighs is to make the respondent give something up to get it. A conjoint or discrete-choice design does this directly: it presents competing treatment profiles and forces a choice between them, so that valuing one attribute more means accepting less of another. The number that comes out is a relative weight, not an endorsement. The same man who says, in isolation, that ejaculation matters to him will, when made to choose between a treatment that preserves it and one that relieves his symptoms faster or carries less risk of a serious complication, often choose the second. Both answers are his. They are not in tension. They measure different things.

The headline a preference study produces is governed by whether it forces a trade-off. This survey used the format that inflates, and declined to report the format that would have deflated.

What the instrument contains

The two figures the paper leads with come from Q10 and Q11. Q10 asks, on a five-point importance scale, how important maintaining erectile function after surgery is. Q11 asks, on the same scale, how important it is to also maintain the ability to ejaculate normally — under an explicit instruction to assume erectile function has already been preserved. The conditional framing is not neutral. Having been granted one preserved function, the respondent is invited to add a second at no cost, and the word also does the work. Neither item asks him to weigh sexual function against anything.

The instrument was capable of asking him to. Item Q9, for men considering surgery, asks what the most important considerations are when choosing a type of BPH surgery and instructs the respondent to select up to two. The options are time under anaesthesia, hospital stay, risk of side effects, recovery, and having a catheter. Sexual function is not among them. The one question in the survey that forces a ranking of priorities does not offer the attribute the paper is built around. Its retrospective twin, Q3S, has the same structure and the same omission. Neither question’s results appear in the paper.

The survey also asked the trade-off outright. Q14 and Q10S put the proposition in a single sentence — willing to sacrifice sexual function for symptom relief, agree or disagree — and Q9S asks the respondent to agree or disagree that every surgical option seemed to require a trade-off between symptom relief and side effects. These are the items that would have told us what sexual function weighs against the thing men actually present for. None of their results are reported. The complete published record consists of the article body and a single supplementary file, the questionnaire itself; the answers to Q14, Q10S, Q9S, Q9 and Q3S are in neither.

The discussion’s claim that men “did not realize how important” sexual function was to them — the basis for the paper’s regret narrative — rests on item Q17S, two statements the respondent is asked to endorse: that before surgery he did not realize how important maintaining sexual, and then ejaculatory, function was. The statements presuppose the importance and measure only whether he will say he failed to appreciate it. There is no counterbalancing item, none asking whether he worried about sexual function more than the outcome warranted. An instrument that offers only one direction of agreement manufactures the conclusion it then reports.

One device appears in the instrument by name in a question of its own. Q20, shown to both groups, asks whether the respondent’s urologist discussed Aquablation therapy with him. There is no equivalent item for UroLift, for Rezum, or for any enucleation technique. A question measuring the discussion penetration of a single named product is market research; its presence in a patient-perspectives survey, in a study whose sample contains exactly one Aquablation patient, tells you what the instrument was partly built to find out.

What men choose when they have to choose

The independent literature that uses the harder design reaches the opposite headline. In a conjoint analysis of 812 men, forcing a choice between treatment profiles defined by efficacy, recovery difficulty, complication risk, and de novo ejaculatory dysfunction, the risk of a serious complication was the most heavily weighted attribute and ejaculatory dysfunction was the least. That sample skewed younger and milder than a surgical population — a group that should, if anything, weight sexual function more heavily rather than less — and ejaculation still came last.

The same study put the older question to its own participants as well. Asked to rate, in isolation, how important maintaining ejaculation was to them, the men scored it four out of five, and then, forced to choose, placed it last. The divergence is not an artefact of comparing one population with another. It appears within a single cohort, turning only on whether the question made them trade. And the authors of that study say as much about the survey discussed here: its finding that sexual function mattered to nearly everyone regardless of age came, they note, from a design that never required participants to rank one attribute against another.

A 2026 multicentre study of 622 surgical candidates and 82 surgeons, using validated symptom and erectile-function instruments and asking both groups to rank their priorities, found continence ranked first by patients and surgeons alike. Ejaculation was ranked low overall, though a minority of patients placed it high. These were not men indifferent to sex: the study excluded sexually inactive patients, so its sample was sexually active surgical candidates with moderate-to-severe symptoms — again the group with the most reason to weight ejaculation — and they still placed it near the bottom. That heterogeneity is real and it matters, which is precisely the point the universal claim erases.

Earlier discrete-choice work reaches the same structure from the medical-treatment side. Side effects carry weight, but men with moderate symptoms weigh sexual side effects less than men with mild ones, because the symptom a man is trying to escape grows more salient as it worsens. Preference is not a fixed trait of the patient. It moves with how much the disease is costing him and with his age.

This is where the survey’s framing does its quietest damage. The paper concedes in passing that the importance of sexual function declines with age, then writes its conclusion as though it does not, asserting the importance “regardless of their age.” The population that surgery for large glands actually serves — older men with severe symptoms — is the population that in every independent dataset weighs ejaculation least and continence and symptom relief most. A device positioned on sexual preservation is positioned on the axis that matters least to the men most likely to receive it.

The pattern

The limitations the survey concedes — the small sample and the recall bias — are about precision. The problem here is not precision. The instrument was designed so that sexual function could score high only where scoring high costs nothing, and the one place the survey forced a real trade-off was either stripped of the relevant option or left unreported. The conclusion the paper delivers, that patients hold sexual preservation paramount and that the sponsor’s device uniquely serves it across all prostate sizes, is not what the survey measured. It is what the survey was shaped to produce.

This reaches beyond one brief communication because the value framework a paper like this installs sits upstream of the trials that follow. Before a device proves anything about outcomes, the literature has to be persuaded that the outcome the device is best at is the one that counts most. A patient-preference survey funded by the manufacturer, built to foreground the attribute the device wins on and to suppress the measure that would qualify it, is how that persuasion is done. The endpoint engineering documented elsewhere in device trials has a precondition, and this is what the precondition looks like.

The survey was designed and funded by PROCEPT BioRobotics, manufacturer of the Aquablation system, and conducted by a third-party research firm. Three of the five authors disclose that they were investigators in PROCEPT studies and are consultants to the company. None of that is concealed, and none of it is the argument. The argument is in the instrument, which anyone can read, because it is the only supplementary file the paper provides.

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Sources

Bouhadana D, Nguyen D-D, Zorn KC, Elterman DS, Bhojani N. Patient Perspectives on Benign Prostatic Hyperplasia Surgery: A Focus on Sexual Health. J Sex Med 2020;17(10):2108–2112. https://doi.org/10.1016/j.jsxm.2020.07.006

Huffman PJ, Yin E, Cohen AJ. Evaluating Patient Preferences in Benign Prostatic Hyperplasia Treatment Using Conjoint Analysis. Urology 2022;164:211–217. https://doi.org/10.1016/j.urology.2022.01.012

Basaran A, Kazan O, Canakci C, et al. Understanding Patient and Surgeon Priorities in Prostate Enucleation Surgery: Insights From the ENUC-TR Multicenter Cross-sectional Study. Urology 2026;211:89–93. https://doi.org/10.1016/j.urology.2026.03.010

Watson V, Ryan M, Brown CT, Barnett G, Ellis BW, Emberton M. Eliciting preferences for drug treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia. J Urol 2004;172(6 Pt 1):2321–2325. https://doi.org/10.1097/01.ju.0000140957.31325.7f

Eberth B, Watson V, Ryan M, Hughes J, Barnett G. Does one size fit all? Investigating heterogeneity in men’s preferences for benign prostatic hyperplasia treatment using mixed logit analysis. Med Decis Making 2009;29(6):707–715. https://doi.org/10.1177/0272989X09341754

Malde S, Drake MJ, Tikkinen KAO. Patient Values, Preferences, and Expectations for Managing Symptoms Due to Benign Prostate Obstruction. Eur Urol Focus 2025;11(4):568–570. https://doi.org/10.1016/j.euf.2025.05.018

Emberton M. Medical treatment of benign prostatic hyperplasia: physician and patient preferences and satisfaction. Int J Clin Pract 2010;64(10):1425–1435. https://doi.org/10.1111/j.1742-1241.2010.02463.x

When the Evidence Is Sponsored: What a New Systematic Review Tells Us About MIST Data and the Guidelines Built on It

#MISTAudit

Most debates about minimally invasive surgical therapies (MISTs) for benign prostatic hyperplasia argue over numbers — reintervention at five years, ejaculatory preservation, symptom scores. A 2025 systematic review in World Journal of Urology by Akgul and colleagues does something more uncomfortable. It argues about where the numbers come from. And its finding is one the field has been reluctant to state plainly: the evidence base underpinning several MISTs is structurally compromised by industry sponsorship, to a degree that should change how cautiously we read it — and how cautiously guidelines should borrow from it.

This is not a fringe critique. The author list includes Thomas Herrmann, Christopher Netsch and Jens Rassweiler — senior figures in European endourology, not outsiders with a grudge. And notably, the review itself declares no industry funding and no competing interests. An audit of sponsorship that is itself unsponsored carries a particular kind of weight.

The headline numbers

Across 99 studies and 12,230 patients, the authors applied a structured conflict-of-interest framework assessing funding, sponsor influence and objectivity. The result: funding was rated high-risk in 65% of studies, direct sponsor influence was evident in 52%, and only 18% of studies were low-risk across all criteria. The remainder sat in the moderate band.

Take that in. In fewer than one in five studies could the authors find independent funding, minimal sponsor involvement and unbiased reporting together. For a literature that feeds directly into clinical recommendations and patient counselling, that is not a footnote. It is the headline.

The picture by technology

The aggregate figure is striking, but the per-technology breakdown is where the review becomes difficult to wave away, because these are simply the paper's own counts.

For Aquablation, 9 of the 11 included studies were rated high-risk for funding, and only one was independently funded. For Prostatic Urethral Lift, the majority of the studies were conducted by NeoTract, with 13 rated high-risk. For Water Vapour Thermal Therapy, 10 of the studies were high-risk, dominated by Boston Scientific and NxThera. By contrast, prostatic artery embolisation and iTIND — the technologies with the least commercial champion behind them — were predominantly independently funded and carried the lowest COI risk.

There is an obvious objection to anticipate here, and it is worth meeting head-on rather than hiding from. The same review reports that Aquablation has among the lowest reintervention rates of any MIST — roughly 4.4% to 6% at five years, more favourable than WVTT or PUL. Doesn't that vindicate the technology regardless of who paid for the studies?

It would, if those favourable durability figures came from somewhere other than the very studies the review flags. But they don't. The reintervention data most often cited for Aquablation derive overwhelmingly from the PROCEPT-funded WATER and WATER II programmes — precisely the high-risk studies in this matrix. The favourable profile and the sponsorship are not two separate facts to be weighed against each other; they are the same fact seen from two sides. A reassuring number produced inside a sponsored trial with narrow entry criteria is exactly the kind of number this review is asking us to handle with care.

The mechanism that should worry guideline panels

The deeper contribution of the paper is not the COI tally — it is the description of how the bias operates, which is more subtle than overt data manipulation.

Industry-initiated studies, the authors note, tend to apply narrowly tailored inclusion and exclusion criteria. Carefully selected patients — the right prostate size, the right anatomy, no awkward comorbidities — yield clean, favourable results. Those results then get presented, and read, as if they describe the broad real-world population a urologist actually treats. The broad-inclusion studies that would test whether the findings generalise are, in the authors' words, still awaited. In the meantime, the favourable narrow-population data flow upward into systematic reviews and, from there, into guideline recommendations.

That is the chain the review asks us to look at honestly: restrictive entry criteria, favourable output, extrapolation beyond the population studied, and finally codification in guidance. Each link looks reasonable in isolation. The aggregate is a recommendation resting on evidence that was never designed to support it.

The authors are explicit about the implication. Extrapolating these findings into clinical guidelines, they write, can be problematic given the potential conflicts of interest — and priority should go to long-term studies with independent funding. This is not anti-MIST. It is anti-credulity.

This is a literature-wide problem, not a single-device scandal

It would be a misreading to take this paper as an indictment of any one technology. Aquablation, WVTT and Optilume all show genuinely favourable long-term reintervention outcomes in the review; the authors say so directly. The point is not that these procedures don't work. It is that our confidence in how well they work, and for whom, is calibrated against a body of evidence that 65% of the time was funded by the party with the most to gain — and that this should be made visible rather than quietly absorbed.

A supporting study the review cites makes the human side of this concrete: Singh and colleagues found that authors receiving industry payments published more positively on UroLift and Rezum, and that 80% of them did not declare the conflict. The influence is not hypothetical, and it is not always disclosed.

Where this leaves the audit

The constructive conclusion Akgul and colleagues reach is the right one, and it is one this series has argued for repeatedly: structured COI assessment should be built into the systematic reviews that feed guidelines, not treated as an optional disclosure line at the end. If a recommendation rests largely on high-risk, sponsor-influenced, narrow-inclusion evidence, that fact belongs in the strength-of-recommendation reasoning — not buried in a supplementary table.

We don't need fewer MISTs. We need evidence that earns the confidence we place in it, and guidelines honest about the difference between what was demonstrated and what was extrapolated. A systematic review written by senior urologists, with no industry money behind it, telling us that more than half their own field's evidence shows sponsor influence, is about as clear a signal as the literature is going to send.

The numbers we argue over are only as good as the studies that produced them. This paper is a reminder to keep asking who paid for the study before we quote the result.

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Akgul B, Tozsin A, Aydın A, et al. Reintervention rates after minimally invasive benign prostatic hyperplasia therapies: a systematic review including industry involvement. World J Urol 2025;43:494. doi:10.1007/s00345-025-05884-y — PubMed

I AAU International Course on Anatomical Prostatic Enucleation — Jerez, 21-22 May 2026

Technology adds value when it is integrated around a clear anatomical concept. Without that concept, changing lasers is just changing labels. With it, any serious platform delivers comparable results — and understanding the underlying physics stops being an academic luxury and becomes a clinical tool.

The simultaneous live surgery format, with honest comparison between international and national schools, raises the level of every conversation in the room. There is nowhere to hide: decisions are visible, mistakes are visible, corrections are too. That is real training.

The institutional dimension is decisive. The joint presence of heads of service from Andalusia's public urology network at the closing session turns this course into a platform for transformation, not just technical dissemination. The AAU has done something unusual here: aligning training, evidence and healthcare management in the same room.

Thanks to Álvaro Juárez Soto and the team at Hospital Universitario de Jerez for the organisation, to the AAU for supporting this format, to the sponsors for participating as educational partners rather than protagonists, and, above all, to Belén Barba and Miguel Ugidos for proving that the course subtitle was not rhetorical. A special and deeply felt mention to all the invited speakers and surgeons, national and international: Cesare Marco Scoffone, Martin Kanne, Jean Baptiste Roche, Thiago Hota, Alfonso Gimeno, Javier Sánchez Macías, Moisés Rodríguez Socarrás, Julio Fernández del Álamo, Nelson Canales, Javier Amores and each of the moderators who covered the sessions with surgical judgement and without seeking the spotlight. You travelled, you operated in someone else's theatre, you taught openly and you discussed every technical decision without hiding anything. That generosity — which is far from trivial in this field — is what turns a well-programmed course into a memorable one. I know what it means to leave your hospital, your team and your routine to come and operate and teach without a safety net, and I am personally grateful for it.

And above all to the 75 registered urologists who filled the room for both days. You did not come to watch: you asked questions, you debated, you pushed with uncomfortable challenges during the breaks and each of you left with one concrete idea for Monday morning's clinic. Without an audience that engaged like yours, this format does not work; with one like yours, it becomes a real instrument of change.

We all go home with the same feeling: euphoric, energised, determined to keep pushing. The goal has not changed and it is very clear — that every patient in Spain, regardless of their hospital or their postcode, should have access to this remarkable technique. That is why we came, that is why we keep publishing, training and operating live, and that is why we will return to Jerez. And wherever else is needed. We keep going.

Four conclusions I take home, which justify the AAU consolidating this format as an annual event:

1. Anatomical en bloc enucleation can be learned during residency. Belén Barba and Miguel Ugidos proved it live, operating as primary surgeons in front of an international faculty. This is not a theoretical argument.
2. Expert tutoring on the ground — not on video, not in a wet lab — is the single factor that most compresses the learning curve. Javier Amores fulfilled that role with a level of discretion and effectiveness that deserves explicit recognition.
3. Technology adds value when it is built around a clear anatomical concept. Without that concept, changing lasers is just changing labels. With it, any serious platform delivers comparable results.
4. The simultaneous live surgery format, with honest comparison between schools, raises the level of debate. There is nowhere to hide: decisions are visible, mistakes are visible, corrections too. That is real training.