#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.
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
