Better Stream: The iTind Procedure for the Treatment of BPH

Better Man Clinics 

Most men who go to their primary care doctor with BPH symptoms will be started on some type of medication rather than being referred for surgery.  When should men start to consider surgery for their BPH symptoms?

Dr. Elterman  

Well, you have to remember a couple things. Number one is that BPH, or what we call lower urinary tract symptoms, which are the symptoms you experience from having a large prostate, really do impact men to varying extents. And one of the main measures that helps us decide when to intervene and do a surgery, for example, or start any form of treatment, is bother. How is BPH impacting your quality of life? If you are urinating perfectly well, you’re sleeping through the night, and your doctor happens to say that you’ve got an enlarged prostate, you don’t really need anything done. But, if you are starting to experience the hesitation of your urinary flow, starting to have a slow stream, noticing a stream that is stopping and starting, not emptying your bladder, dribbling after urination, or waking up at the night to urinate – then BPH is now affecting your quality of life. Now it’s starting to bother you. And this is when you want to start getting treatment. Now, the paradigm is really shifting.  We used to wait until the very last moment before we offered someone surgery because it was invasive, at least the old roto rooter (TURP) was. But now, we’re kind of flipping that on its head and saying, “Well, we’ve got these less invasive options, these minimally invasive surgical therapies (MIST). And we also have a better understanding of the role of intervening earlier to preserve bladder function. Then, in other words, it’s not just quality of life and the symptoms, but that we also want to protect your bladder from being permanently damaged over time. The earlier we intervene, the better we can actually prevent that damage from happening.”  So now, we don’t have to wait until the very last moment until a man is almost in retention and can no longer urinate. We are actually able to offer treatments earlier and earlier in men who are bothered by their urinary symptoms.

Better Man Clinics  

Well, that is quite a change in paradigm. I’m assuming that, at least, part of the reason for that change is that these new MIST or minimally invasive surgical treatments or therapies probably have less side effects and risks than the traditional roto Rooter or TURP procedure. Would that be correct?

Dr. Elterman  

That’s absolutely correct. You know, I often think about this continuum of risk and benefit. Medications or pills that you take like tamsulosin (Flomax) or other alpha blockers have relatively low risk, but relatively mild benefit.  We see small improvements in symptoms and small improvements in flow (stream). On the other end of the spectrum are high risk, high reward surgeries like the TURP or the Roto Rooter.  They are really great at removing prostate tissue. Dr. Krambeck, in another other episode, talked about HoLEP which is similar to the TURP.   That procedure is very good at removing a lot of tissue. But they come with certain risks: having to stay in the hospital overnight, full general anesthesia, bleeding, retention, scar tissue regrowth, etc. And, so, where these new minimally invasive or MIST procedures fall is somewhere in the middle.   They’re going to be more beneficial than medications, but less risky than those traditional surgeries.

Better Man Clinics 

Got it. And so now let’s dive into what we’re actually doing in these procedures.  The analogy that has been brought up in a couple of episodes now in terms for guys to understand is that the prostate is like a doughnut, and you’re peeing through the doughnut hole. The idea for a TURP or HoLEP is that we’re getting rid of a lot of that inner part of the doughnut, shaving it away, cutting it away, lasering it away, so that the only thing left is the outer, if you will, glaze of the doughnut rather than the doughnut itself. That leaves a much larger passageway to urinate through. How is iTind different? 

Dr. Elterman  

It is entirely different.  This is a completely different way of thinking about improving the flow through the prostate. Other types of procedures, like you just mentioned, are removing tissue, they’re ablating or resecting. In other words, we’re actually cutting away or removing tissue.  iTind is an acronym that stands for temporary, implantable, nitinol device. What the iTInd is doing is it’s actually creating these deep incisions or grooves into what’s called the bladder neck and prostate by inserting this temporary device into that area. And what it does is it expands very slowly (over a five to seven day period) and it creates these deep incisions or grooves into the prostate, essentially opening up the prostate, increasing the diameter of the passageway through the prostate without actually having to remove any tissue.  It is a cut-free way of improving flow. And so the iTind- I know we’re on video so I’ll try and hold one up here- is this little device with these struts. The idea is that the struts expand up at 12, five and seven o’clock. And when it’s left in place, it will create these deep grooves and then after five to seven days, the entire device is removed. There’s nothing left over inside the body. That’s not a permanent implant. It’s not a permanent stent.  It is just temporarily placed.

Better Man Clinics  

How would you compare the idea or mechanism of iTind with other minimally invasive (MIST) procedures such as UroLift or Rezum?

Dr. Elterman  

UroLift is a permanent implant where you place sutures through the prostate to pin back the lobes. Rezum is this water steam treatment where you’re injecting water heated up to kill the cells in the prostate, causing it to slowly shrink down. iTind is different in a number of ways. Number one, unlike UroLift, it’s temporary. Nothing is left inside the body. You don’t have to deal with foreign material and whatever complications you may have from that. Number two, it could certainly be easily repeated in the future. Number three, the way that it’s actually delivered is very different. UroLift and a Rezum are carried out with a rigid scope. In other words, it’s a long instrument (telescope) that’s firm. And so, there’s a certain degree of anesthesia needed or discomfort associated with putting it in.  The iTind is designed to be used with an off the shelf flexible cystoscope. So, urologists in the office have the ability to use just local anesthesia with gel.  You can pass a regular diagnostic cystoscope as you normally would. And then, through that scope, you can actually then place the iTind into the bladder and, under direct vision, you can actually just pull it right back into the prostate and deploy it. So, the iTind provides the ability to do the procedure in the office, under local anesthesia, with a flexible scope and no special equipment required.  The Urologist doesn’t have to buy a new special scope as required for the UroLift and they don’t need to have a machine as for the Rezum. It really is an off the shelf solution for any Urologist in any patient in any practice. 

Better Man Clinics  

Who is the ideal candidate for iTind?  How does that ideal candidate compare to the ideal candidate for traditional therapies like TURP or HoLEP or MIST therapies like UroLift or Rezum?

Dr. Elterman  

I think the group of men that the iTind could be useful for is actually a very broad range. It could be men with smaller prostates, who would typically be placed on medications. In this case, iTind could be seen as an alternative to medication, I think that’s really where the greatest potential benefit is.  You have so many hundreds of thousands or millions of men in the United States who are on these drugs. Instead of taking one or two pills every day, you could go to your urologist’s office, have the iTind placed in five minutes, have it removed after five to seven days, and you no longer have to take a medication. On the other end of the spectrum, there are a certain number of men who are failing drugs and who are heading towards surgery.  A good number of them could instead get iTind.  Now, there are certainly men who have much bigger prostates. And so, we have a range of volumes. We usually measure prostate size in CCs or milliliters or grams. So the iTind has been studied in prostates between 25 or 30 and up to about 80 grams. That is also what’s being studied for UroLift and Rezum. If you’re getting above 80 grams, you’re probably looking at a TURP or HoLEP.  But, the majority of men, probably 75% to 80%, are going to be below 80 grams and would be very good candidates. The caveat for the iTind may be men who have what’s called a very large median lobe of the prostate. The device may not sit properly in the prostate if you have a large median lobe.

Better Man Clinics  

The median lobe is that part of the prostate that pushes up into the bladder.  There is no way to know that you have a median lobe unless your urologist basically does a camera test (the cystoscopy) in the clinic, correct?  They wouldn’t know that based on your symptoms, for instance?

Dr. Elterman  

That is correct. But again, one of the nice things I envision about an iTind is that if you have urinary symptoms and you go see your urologist, they’re likely going to say, “we’re going to take a look inside with the cystoscope today to find out if prostate is suitable and of a certain size and doesn’t have that large median lobe. Would you like me to pop this iTind in right here today and you don’t have to come back for a second procedure and you don’t have to come for anesthesia?”  Then, not only has the cystoscopy been diagnostic, it has now also become therapeutic. You are actually getting your treatment and your diagnosis at the very same time.

Better Man Clinics  

You said that the that the ideal size of the prostate for iTind is 25 to 80 grams. For context, what’s the typical size of a “normal” prostate?

Dr. Elterman  

We consider prostate enlargement to begin at 30 grams. Younger guys like me probably have a prostate less than 30 grams. Teenagers have prostate they’re like 15 grams or 20 grams and it only starts to become enlarged after 30 grams. So, prostates 30 to 45 grams or 50 grams would be considered mildly enlarged and prostates 45 or 50 grams to say 70 grams would be medium or moderately enlarged, and the really big prostates are going to be 80 grams and above.

Better Man Clinics  

Aside from having a prostate larger than 80 grams in size, are there any other contraindications to the iTind procedure?  Any other situations or conditions that would make the iTind procedure not advisable?

Dr. Elterman  

You know, I think the size is the main thing.  The device is made out of nitinol, which is a metal alloy. So, you may have a very rare allergy. Obviously, if there’s an issue with your urethra, like a stricture (scar tissue) preventing you from getting devices in and out, that could be a problem. You cannot do any of these procedures with an active urinary tract infection.  If someone has prostatitis (infection or inflammation of the prostate), you’re not going to want to do it. But besides that, I would say that it’s fairly applicable to most men who come into the urologist’s office,

Better Man Clinics  

Could men who are on blood thinners (aspirin or Coumadin or Lovenox) still get the procedure or do they have to be off of those blood thinners first?

Dr. Elterman  

You know, I do think it carries a risk. There’s never been a specific research study that looked at men on blood thinners undergoing the procedure.  However, I would say that because it is not cutting, it’s only essentially stretching, that the risk of bleeding is probably very low.  The risk is lower than the other MIST procedures like UroLift in which a needle actually punctures the prostate.  So, I’d say there’s always a small risk of bleeding with any procedure done to the prostate just from the mechanical pushing. But I do think the risks are relatively low.

Better Man Clinics  

Do men undergoing the iTind procedure still need to stay on BPH medication afterwards?

Dr. Elterman  

The goal is to be able to allow men to get off of their medications. And it’s our feeling, as I’m one of the investigators for the research, that once you undergo iTInd, like the other MIST procedures, you should be able to come off your drugs.  I usually have the men, whom I do the procedures on, stay on their medication for about a month. Immediately after the procedure, there may be a little bit of swelling, so you want their Flomax to help them out for a bit.  By the time they reach around 30 days after the procedure, they can then stop their BPH medications. That is definitely an advantage of doing a procedure: you can get off your drugs.

Better Man Clinics  

If I’m coming to your practice and I’m interested in getting the iTind, what should I expect at the urologist’s office in terms of evaluation?

Dr. Elterman  

When you come into urologist’s office with urinary symptoms, we’re going to want to establish that it really is the prostate that is the culprit and that there’s not something else going on like an overactive bladder.  You have to remember that if your main symptom is frequent urination, urgency, or waking up at night with urgency, it may be a bladder issue and you may not need anything done to your prostate. Other types of evaluations may include some questionnaires.  We give people questionnaires like the International Prostate Symptom Score -it’s a bunch of questions with a number value attached to them. We add up the points for each question and see how severe your symptoms are. Sometimes what we’ll do in the office is measure the velocity of your urinary flow. We will have you pee into this funny little funnel, and it measures how fast your stream flows.  After that, we’ll do a little ultrasound on your lower abdomen (your tummy) to see if you leave behind any urine in your bladder after voiding. The next thing may be a cystoscopy, where we want to look in with the camera and see the shape, the length, and the approximate size of your prostate, as well as the condition of your bladder. Increasingly, a lot of urologists are ordering some form of an ultrasound or imaging to be able to assess the size of your prostate.  This measurement of the prostate volume helps us better determine if you’d be a suitable candidate for one set of procedures versus another. So essentially, the workup is talking to you, getting your history, maybe filling out some questionnaires, assessing your flow, and then assessing your prostate.

Better Man Clinics  

Do you need to have a rectal exam as part of the evaluation?

Dr. Elterman  

I think that’s sort of par for the course. Sort of like if you go to the cardiologist, they’re going to listen to your heart. So yeah, we’ll probably check your prostate as well.

Better Man Clinics  

What are the risks of iTind that you counsel your patients on before the procedure?

Dr. Elterman  

The risks are going to be temporary things that you would experience while the device is in. You could feel a pressure. Remember, this thing is opening and stretching in your prostate.  Some men may experience that as pain or discomfort. But I think that’s understandable. Blood in the urine for a few days is possible.  Also, irritation by the device can cause frequent urination or urgency that, again, specifically occurs for these five to seven days that the device is maintained inside the body. Anytime you do a procedure in the urinary tract, there’s a risk of urinary tract infection or UTI. Those I think are the main risks: irritation, discomfort, bleeding, infection. Now, there are also device related risks. The device does have the potential to become dislodged. It is very unlikely because it does have a leaflet on the bottom of the device, that holds it in place. But, of course, you do have the risk of migration. For men who are really living on the edge of going into retention, anything done to the urinary tract can push them into the retention, so you always have the possibility of not being able to pee once it’s in. If that were the case, we’d put in a very small catheter, actually just alongside the device, leave it in for the five to seven days and then remove them both. So that’s a possibility as well.

Better Man Clinics  

Is erectile dysfunction a risk of the iTind procedure?

Dr. Elterman  

We have analyzed the data through a large research study we have found that there are no changes to erectile function with the iTind. In other words, your erections will remain unchanged.  They are not going to get better and they’re not going to get worse. Interestingly, there was a subgroup of younger men whose erections got a little bit better. But overall and generally, erections stay the same. The next question, you’re going to ask me centers around ejaculation.  Ejaculation is also 100% preserved with iTind. We did not see any men reporting changes like retrograde or dry ejaculation or dry orgasm after iTind. The reason for this is that we are not cutting or destroying the very important structures that keep ejaculation intact. The third thing you may ask about is urinary incontinence- whether you’re going to leak urine. The answer is no. Some men have some urgency and they may have some temporary leakage while it’s in. But the device is designed to sit within the prostate. And it’s not at the level of the muscle of control called the sphincter.  Therefore, it should not cause any permanent incontinence

Better Man Clinics  

Is there any preparation that is required prior to undergoing the iTind procedure?

Dr. Elterman  

Depending where you get it done, it may be done with light sedation like you get during a colonoscopy. As a result, you may need someone to give you a ride home. Even if you’re getting a local anesthetic, you may want to have someone to pick you up and drive you home because you’re going to have this device in your prostate and you may not feel very comfortable to drive home. In terms of other preparations, you’re going to get a urine test and maybe a blood test prior, just to make sure you are ready to go for the procedure. That is pretty much the preparation that’s required. At the end of the device, there’s a string which goes all the way out through the tip of your penis. During the procedure, we coil the extra string and stick it onto the back of your penis with a little band aid. The reason for this is that, when you come back in five to seven days, we actually remove the device by pulling on the string. In reality, we put the string through a catheter, and we actually insert the catheter, and we’ll pull on the string so that the device collapses, like an umbrella, into the catheter. Then we remove everything. That’s how it gets removed. So, you can expect that, when you leave the clinic, to have this little string. We will remind you not to pull on the string.

Better Man Clinics  

How long does this whole procedure take to do?

Dr. Elterman  

It has been touted as the five, five and five procedure: five minutes to put in, five days left in place, and five minutes to remove. I would say that, realistically, it could be done in less than 20 minutes. The removal does actually take 5 minutes, however.

Better Man Clinics 

How much discomfort should someone expect when the device is inserted and/or removed?

Dr. Elterman  

We are manipulating a very sensitive part of the body and we’re doing it under minimal anesthesia. We want it to be quick, easy, and painless, I do think you have to prepare men that this device is going to be left inside and it’s going to be slowly expanding to create these grooves in the prostate. It is actually reshaping your urethra and your prostate. As such, I would tell men to expect some level of discomfort. However, it’s really subjective. I have men come in and they say, “Doc, I didn’t really feel much.” However, there are other men who say, “Boy, I can’t wait to get this out.” Either way, the discomfort is going to end.  It is only in place those five to seven days. So, if you can tolerate it, and obviously everyone does. You’ll be fine.

Better Man Clinics  

Do have to take a lot of pain medicine while the device is inside during those five to seven days? Do they require that?

Dr. Elterman  

We certainly offer it, but I don’t think it’s a very large amount. About 20% of men will have some irritation or burning when they pee. But significant pain was experienced by like less than one 1% of subjects in the clinical trials. So, we definitely say you can take Tylenol, Advil, other types of pain medications.  If it gets really, really severe, you can take stronger medications under the direction of your doctor, but I haven’t really had that experience.

Better Man Clinics  

One complaint we hear about after Rezum is sloughing- they might see some tissue or something come out. Would you expect the same thing from iTind as the device is expanding? Is it destroying tissue that then has to pass through your urethra or not really?

Dr. Elterman  

Not really.  It is really like a focused incision, a groove that’s being cut. The difference is that it is unlike a knife which cuts immediately and then the cut will heal shut. The whole mechanism of the iTind, which is brilliant, is that it is slowly expanding through pressure over those five to seven days. So you are making these grooves but you’re not removing tissue and you’re not really killing it and you are not going to see large chunks of tissue that are going to have to be passed out or expelled. 

Better Man Clinics  

Do men have any restrictions during the 5 to 7 day period during which the device is in the body? Is there anything they shouldn’t do during that period of time?

Dr. Elterman  

Well, we tell them to take it easy. You know, I really tell them, “Don’t go to the gym- no exercise, no bicycle riding.”  People are going to feel that tightness in their prostate and we want them to get through those five to seven days without too much difficulty. No sexual activity, of course, as you’ve got the string coming out of your penis. Those are typically the main sort of physical activities that you want to restrict just for those seven days.  Once the device is out, there are no restrictions.

Better Man Clinics  

Do people generally just continue to work during those five to seven days after the procedure?  They do not need to remain at home?

Dr. Elterman  

No, they’re not home bound. I mean, they may want to take a couple of days off just to sort of see how they’re adapting to the device.  You might want to do it over a weekend.  However, it’s certainly not going to put you out on your back like a major surgery would.

Better Man Clinics  

Are you completely recovered after the device is removed in 5-7 days?

Dr. Elterman 

You may have some residual symptoms such as a little bit of burning and frequency that sort of tapers off over the subsequent days but that’s about it.   It really is what we call self-limited. It resolves on its own very, very quickly.  You’re not going to have prolonged symptoms weeks and weeks after the device is removed.

Better Man Clinics 

One criticism of the MIST procedures has been durability. Generally speaking, if somebody goes through the TURP, or roto-rooter procedure, he is told that the effects are good for 10 or 20 years. In contrast, if you’re looking at UroLift or Rezum, some people have quoted the need to be retreated in a year or two years or three years. Understanding the iTind is a new procedure, is there data available about its long term durability?

Dr. Elterman 

The big US study that was just published this year includes just one year of data. There is an Italian study that looked out to three years and it demonstrates that iTind has pretty good durability, similar to Rezum or UroLift.  It’s not going to have the same durability (no MIST procedure will) as a TURP or HoLEP because you’re not removing tissue. But I would flip this idea on its head and I would argue that durability, the long lasting effect of a procedure, shouldn’t be the only gold standard or the most important thing. I think that if a procedure like the ITind is easy, fast, and low risk, what’s wrong with putting one in and getting symptom relief for one year, two years, or three years, and then coming back and getting it repeated?  We go to the dentist a couple times a year and we don’t tell them that they’re doing a poor job.  You have to keep going back.  You can think of it as maintenance. Or you can think of it as an alternative to medication.  Instead of taking your pill every day, you are undergoing this procedure once a year, or once every two or three or four years.  I don’t think this idea of durability is so important because the trade off you’re making is that it’s less invasive and it has lower risks.  As such, it’s easier to repeat.

Better Man Clinics  

With the TURP or “Roto-Rooter”, doing a repeat procedure tends to have some added risk to it because the anatomy is a little bit different after the procedure.  For example, there could be a higher risk of incontinence because you’re cutting tissue away during the initial procedure and the landmarks aren’t quite there any more. Do you face similar added risk after an iTind procedure?

Dr. Elterman  

This question hasn’t specifically been studied.  However, in my opinion, I think what you’ve done is you’ve made these incisions, you’ve reshaped the prostate. Over time, if those incisions or grooves start to close up, or the prostate starts to continue to grow, there’s no reason why you can’t reintroduce an iTind and have it do its thing for those five to seven days and see how it goes. If you are beyond the point where the iTind or any other MIST procedure is achieving the effect you want, then maybe it is time to go for a TURP or something similar. But there’s no reason that you can’t retry it.

Better Man Clinics  

One of the issues about redo procedures after the UroLift is the difficulty with the indwelling material left behind after UroLift. There have been concerns mentioned that, because there’s actual something left over, it’s hard to do a TURP afterwards because you’re going to be hitting these anchors or the sutures from the UroLift. I’m assuming that is not the case with iTind because the materials from iTind are subsequently removed after the procedure?

Dr. Elterman  

That’s exactly correct. One of the beautiful things about a device like an ITIN is that, because it’s temporary, it’s doing its work over those seven days, and then it’s entirely gone. As such, it will not interfere with any future procedures. So, it keeps all your doors open.  All procedures are options in the future if you would need them. And there’s no foreign body left inside your prostate.

Better Man Clinics  

How does iTind compare head to head versus TURP and the MIST procedures in terms of outcomes like patient satisfaction?  To what extent does iTind improve the urinary symptoms that men face from an enlarged or obstructing prostate (BPH)?.

Dr. Elterman  

The outcomes appear to be very similar to the other MIST procedures based on symptom questionnaires that patients fill out like the International Prostate Symptom Score (IPSS).  In the three large clinical trials that have been done on iTind, we see the IPSs score reduced by between 45 to 60%. So, that means that their symptoms have improved by 45 to 60%.  So, we see a significant improvement there.  We see that the force of their stream doubles. And, when we look at quality of life, we see their score also significantly improved from “generally dissatisfied” to “satisfied.” So, on the IPSS, it’s a five point scale and they go from a four, which is not very good, to about a one and a half or two, which is quite good. I think that’s very similar to the other MIST procedures.  With TURP and HoLEP, you’re going to see a more dramatic improvement in flow in the symptom score.  You will maybe a see little bit more improvement in the quality of life, but that’s debatable. But, that’s because you’re doing a more invasive operation where you’re really taking away a lot of tissue. So again, that’s that trade off -the degree of improvement you’re going to see and how long the improvement is going to last versus the invasiveness. But, the iTind certainly holds up just as good as those other minimally invasive products that are on the market.

Better Man Clinics 

How many of these iTind procedures have been done, not only by you, but in general?

Dr. Elterman  

There have been close to 300 patients treated in all of the different clinical trials when you put them together. The device has been commercially available in Europe for a number of years, as well as Canada. I was doing these outside of the trial, and they’re available in Germany and Italy and other parts of the world. As such, I don’t have an exact number. It’s not in the 10s of 1000s. But it’s certainly in the hundreds, if not 1000s by now. And, to be clear, it just received FDA approval. This is really coming right onto the scene as we speak.

Better Man Clinics  

Is iTind still considered experimental?.

Dr. Elterman  

iTind is not experimental. The procedure has Full FDA clearance for the treatment of BPH in men. This is treatment is not some off label experimental treatment. This has received full approval from the FDA. Absolutely.

Better Man Clinics  

If I’m a guy interested in iTind, how do I find a surgeon to perform the procedure on me, aside from going to Toronto to see you?

Dr. Elterman  

iTind has a website, I think it’s itind.com. It is carried by a company called Olympus and I think you could probably go on to the Olympus Americas website and they may start to have something called a physician locator. For a lot of these companies, you can look up physicians who offer that particular product. There are surgeons who are now offering the iTind in major cities around the United States. It is available in California( Los Angeles, Bay Area), New York, and Texas. And, every week, there’s a new person who is adopting it in their practice.

Better Man Clinics 

And presumably, if they’re on one of those websites, they are “certified”? Meaning, that they have the experience to do it? It is not just a surgeon just trying it out and seeing what happens?

Dr. Elterman  

No, that’s correct.  Olympus is a very responsible company and there’s a certain level of training and proctorship involved that leads to an understanding of safety and best practices of how to perform the procedure. So, a doctor cannot just call and order the device and just start doing it on their own. There’s a process involved and the same is true for other MIST procedures like UroLift or Rezum – you need to get some level of training and expertise to be certified. And so that’s no different for the iTind.

Better Man Clinics  

Are there any special questions that you would recommend patients asking a prospective surgeon that will be performing the iTInd?  Anything in terms of vetting or any questions that would help them get comfortable with the surgeon and/or the procedure that you would recommend? 

Dr. Elterman  

One of the things that I think is really remarkable about iTind is that it relies upon basic skills that urologists have. And so, I don’t think you need to grill your urologist about how many procedures they have done because all urologists are very familiar with the procedure.  We are all comfortable using a rigid scope and a flexible scope, using guide wires and baskets to get stones. So, this is no different than the basic skill set. It’s not a special technique that has to be learned with a big fellowship or special training. So, I wouldn’t be too hard on your surgeon or your urologist. I think that it’s very much a basic skill, which is one of the great things about it. You can ask them, what’s their preferred method of anesthesia? Would they like to do it under local anesthetic? Would they prefer to do it with a little bit of sedation? Some urologists are doing it with a rigid scope under sedation, which is perfectly acceptable. Some urologists are starting to adopt a newer technique where we use the flexible scope to put it in. I don’t think that should dissuade you one way or the other. But that’s about it. You can ask them what are the medications you’ll be given over those five to seven days and what’s the procedure like to have it removed? 

Better Man Clinics  

Got it? So last question. And this is probably the most difficult one. You are an expert on BPH.  You can perform basically any of these BPH procedures, including the MIST procedures.  I’m a patient walking into your clinic. I have an appropriately sized prostate. I’m very bothered by my symptoms. I don’t want to be on medication anymore. You have all of these BPH procedures at your disposal? What do you counsel me? What do you tell me?

Dr. Elterman  

Well, counselling has become increasingly more complicated because we now have so many options. And, for someone like me, who offers all of them, It’s not so straightforward. You know, the way that I would divide it is I want to be very systematic with the patient. You know, we want to try and offer a tailor made, customized treatment for each individual man. And so, I’m going to ask you some questions to help guide the decision once we’ve already established your prostate is the right size and you’ve got the right symptoms.  I’m going to ask you how you feel about where the procedure is performed.  Do you want it performed in an operating room or do you want it done in the clinic? Do you want to be fully asleep or do you want to do it awake? Do you care about keeping your erections and ejaculation or would you be okay to lose them? How do you feel about having a permanent implant in your body versus something which is removed?  Are you someone who is pretty good about tolerating discomfort or would you rather just have something that’s done under anesthesia that you won’t feel. So those are some of the questions I’m going to ask. And, hopefully, we’ll get to a decision between the two of us. But, there is admittedly a lot of overlap. You know, there isn’t a perfect patient for any specific procedure. There isn’t a perfect patient for Rezum or UroLift.  The perfect patient is probably a good candidate for any of them. So, I try to be very balanced and even handed. I perform UroLift. I perform Rezum. I perform iTind. So, I’m very open, I’m agnostic. But, I think that the iTind has a lot of features that will be appealing to men, and ultimately, it’s going to be what they feel in their gut. That’s what they’re going to go with.