AUA 2024 and reflections on implicit bias

Gopal H. Badlani, MD

The recent American Urological Association (AUA) Annual Meeting in San Antonio, Texas, was a roaring success. The AUA team makes a diligent effort to have conflicts of interest declared before each presentation, but listening to some presentations, I wondered about implicit bias. Like many others, I was not aware of this trait in me until I read an article about the undeclared conflicts of authors of the iconic textbook Harrison’s Principles of Internal Medicine.¹ I reflected on implicit bias and the decisions I have made without being cognizant of it, especially while making presentations at the meeting.

How does one develop this? Is it in the genes, or is it a cultural influence? It is seamless in its ability to get into your psyche; no formal instructions or encouragement are required unlike with explicit bias. It is often implied in humorous conversation and enjoyed by many—unless you are at the receiving end of it. Slowly, society has evolved to consider this unacceptable and empower the various groups to raise their voice when their rights are being violated. The explanation that “I was joking” or was unaware of making the other party uncomfortable does not hold water anymore. In our professional life, awareness of our bias in seeing patients based on their weight, color, age, literacy level, or social status is evident.

At the AUA meeting, I heard presentations on the use of mesh in vaginal surgery. Despite multicenter data showing very low product-related complications,² the implication that vaginal mesh is “bad” and is banned in some countries persists. In the benign prostate session, a complication of a device was presented graphically and implied as device failure, without comment on the operator error of placing it in an unindicated large prostate. Similarly, the controversy of retreatment was presented as “imperfect truth” based on the bias of the presenter. The habits ingrained in our psyche require a superhuman effort to undo.

What is new in benign urology, according to the annual meeting: The new overactive bladder (OAB) guideline makes a major shift from a stepwise management of OAB (behavioral therapy to medications to tertiary treatments) to a shared decision-making process with the patient and a tailored approach to care.³ It removes the barrier of using anticholinergics before ordering β3 agonists. It also addresses their use in male lower urinary tract symptoms (LUTS) and use of OAB medications as single or combination therapy.

This stepwise treatment is prevalent in managing male LUTS and benign prostatic hyperplasia (BPH) (behavioral therapy, α-blockers, combination with 5α reductase inhibitors before intervention with a minimally invasive surgical therapy [MIST] or ablative therapy) despite guideline statement No. 2, which suggests shared decision-making with patients to pursue any of the above options based on bother. The BPH/male LUTS guideline was updated in 2023 to remove “legacy” treatments and add some new devices (iTind, Optilume) to the MIST category.⁴ An interesting presentation in the sponsored session at the Society of Benign Prostate Disease meeting at the AUA showed 3-month data comparing MIST with α-blockers as initial treatment, favoring the MIST treatment. Published data on this trial, called IMPACT, are pending. Also awaited are the full data on comparison of UroLift and Rezum. The role of these new treatments in other countries is interesting as the cost and acceptance of a catheter are barriers. Ejaculatory function is presented as a major factor in a patient’s choice of procedure, despite the patient being on α-blockers for a number of years and having altered emission. I wonder how much the bias of the provider factors in the decision.

“My view is that at a younger age your optimism is more, and you have more imagination, etc. You have less bias.” Former president of India A.P.J. Abdul Kalam (1931-2015)

REFERENCES

1. Marcus A, Oransky I. Authors of premier medical textbook didn’t disclose $11 million in industry payments. STAT. March 6, 2018. Accessed May 13, 2024. https://www.statnews.com/2018/03/06/conflict-of-interest-medical-textbook/

2. Matthews CA, Rardin CR, Sokol A, et al. A randomized trial of retropubic versus single-incision sling amongst patients undergoing vaginal prolapse repair. Am J Obstet Gynecol. Published online May 3, 2024. doi:10.1016/j.ajog.2024.04.036

3. Cameron AP, Chung DE, Dielubanza EJ, et al. The AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder. J Urol. Published online April 23, 2024. doi:10.1097/JU.0000000000003985

4. Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA guideline amendment 2023. J Urol. 2024;211(1):11-19. doi:10.1097/JU.0000000000003698