As he drove on the New Jersey Turnpike, Doug Hikade's biggest concern was never the traffic or the tolls, but the next rest stop.
"I'd be frantic," recalled the Mount Laurel resident, 74.
Like most men his age, Hikade suffered from the squeeze of an enlarged prostate. Unable to completely empty his bladder, he needed to go far more often, sometimes half a dozen times a night.
Hikade is among thousands who have had a quick office procedure in which a urologist inserts tiny sutures that pull aside the two halves of the enlarged gland – almost like curtains on a stage – allowing for improved urinary flow.
"It is total relief," he said.
The procedure, called a prostatic urethral lift, does not improve flow as much as surgery, in which a physician cuts away some of the inside of the prostate to allow better flow. But the lift procedure and recovery are much quicker, with no hospital stay and fewer complications. And patients who get the sutures can always come back for surgery later.
Bruce Sloane, Hikade's urologist, said he was doubtful of the sutures at first until he saw the research data and watched another physician demonstrate the technique. He now has implanted the UroLift sutures in several dozen patients, and said he likes it because it does not involve destroying any tissue.
"If I can preserve a guy and keep him whole, I like that," said Sloane, who practices in Center City.
Another initial skeptic, urologist Steven A. Kaplan of the Icahn School of Medicine at Mount Sinai, now performs the procedure, as well, though he remains unsure how long the improvement will last. In May, researchers said that improvements in peak urinary flow have lasted so far for five years, in a study funded by device maker NeoTract Inc., of Pleasanton, Calif. But one in 10 patients ended up needing surgery anyway.
With the UroLift sutures, quick recovery is among the biggest pluses, said Kaplan, director of the Men's Health Program at the Mount Sinai Health System, in New York.
"They can go to work the next day," he said.
A common problem
Benign prostatic hyperplasia – benign meaning no cancer is present – strikes up to half of men by age 50. By age 70, close to 80 percent have symptoms from an enlarged prostate, said urologist Sloane.
Insurers generally want medication to be tried first, but the drugs do not always work, and can cause dizziness or other side effects.
Both concerns – side effects and lack of effectiveness – motivated Paul Diamantis to come to Sloane's office for the lift procedure in May.
The Haddon Heights resident, 62, had no problems with daytime urination but had to get up to use the bathroom several times a night, he said.
He lay back in a reclining chair in Sloane's office, and rolled to one side so Sloane could inject a numbing agent in his prostate, going through the rectum.
Then Diamantis rolled onto his back, and Sloane injected another numbing agent into the urethra.
The physician then told Diamantis he would insert a cystoscope into his penis, through the urethra, until it reached the inside of the prostate. The thin black tube would serve as a sheath for the device that delivered the sutures. Diamantis seemed a bit apprehensive, pressing his lips together in response.
"Now I want you to relax," Sloane said. "You'll feel it a little bit, but not much."
In went the scope, followed by the delivery device – a long, silvery rod with a trigger handle on one end.
Click! Sloane squeezed the trigger to secure the first suture, which unfolded into a T-shape on one end, hugging the outside of the prostate like a miniature version of those molly bolts that are driven through drywall.
The doctor adjusted the device slightly, then squeezed the trigger again, cutting the other end of the suture to the right length and securing it inside the urethra. The scope was fitted with a small internal camera, allowing Sloane to monitor his progress on the screen of a nearby laptop.
Diamantis got four sutures, two on each side of the walnut-sized gland. Some patients get five or six.
His entire office visit lasted about an hour, but he was back on his feet in minutes.
"It wasn't bad at all," Diamantis said.
Taking action before bladder is ‘shot’
The device got its start more than a decade ago, in a biomedical business incubator in California. Three engineers, Ted Lamson, Joshua Makower, and Joseph Catanese III, spent months interviewing patients and physicians, learning that many were dissatisfied with current treatments for enlarged prostates.
They developed UroLift after experimenting in cadavers, and founded NeoTract in 2004.
The first patients were treated in Australia by the end of 2005. Initial clearance from the U.S. Food and Drug Administration did not come until 2013, but now more than half of the 30,000 patients treated to date are in this country, said chief executive officer Dave Amerson. Insurers generally reimburse about $5,000 for the procedure. Medicare covers it, though some private insurers do not.
Lamson worked with heart valves for his doctorate in biomedical engineering at Pennsylvania State University, a good preparation for his work today. Faulty valves can make the heart work too hard over the long term, and the muscle becomes baggy and weak – the condition known as heart failure.
Ditto for the bladder, if it has to strain to force urine through a channel that is surrounded by an enlarged prostate.
"The bladder has to work a lot harder," Lamson said. "It is getting worse and worse."
Sloane agreed, saying it was an argument for not waiting too long to take action.
"The bladder can regain contractility as long as it's not too far gone," the urologist said. "Once the bladder is shot, you can't bring it back."
In the days following Diamantis' procedure, as with most patients, he experienced more frequent urination, not less, as his bladder adjusted to the unrestricted flow. Sloane said a significant improvement after four weeks is common.
Hikade, who had his procedure in August 2016, was so happy that he talked a neighbor into getting it, and that man has since recommended it to someone else.
And those trips on the turnpike?
"You don't worry about the next rest area," Hikade said. "It's peace of mind now."