Prostate health: ProACT trial helps with post-surgery incontinence
Prostate health is something every man should be aware of yet few people want to discuss. An enlarged prostate – called benign prostatic hyperplasia (BPH) – can lead to the need for surgery, which most often is followed by urinary incontinence issues.
“There is essentially a 100% urinary incontinence rate after removing the prostate, says Dr. Kiran Sury, a urologist at Allegheny Health Network (AHN) Urology in Pittsburgh. “Fortunately, there is significant recovery with time as patients heal, and the data shows that about 90% of men will be dry at a year after surgery.”
The easiest way to think about the treatments for incontinence after prostate surgery is to link them to the reasons men leak.
“When the prostate is removed, men rely on their external urethral sphincter, which is the muscle we all learn to control when we are potty trained as toddlers,” says Sury. “Over the years we stop needing to think about it. The prostate also tends to grow with age, and it functions like a dam, holding back the flow. When the prostate is removed, the dam is gone, and the flood waters can overcome that sphincter. This sphincter is weaker from all the years of relying on the prostate to do most of the work, and it also has some reduced function from going through the surgery.”
The first treatment for patients is physical therapy to learn Kegel exercises to consciously control the sphincter again. This improvement in sphincter function is what gets men back to dry naturally. But for the 10% of men who don’t get there, surgery can help.
The two most commonly used treatments for incontinence are slings and artificial sphincters. The sling is a piece of mesh that functions like a hammock to lift and support the urethra and reposition the external sphincter, so it functions more effectively.
“The best part about a sling is it is a ‘set it and forget it’ option,” says Sury. “Patients don’t have to do anything; they just live their drier lives. However, it doesn’t actually block the leakage, it just augments the body’s natural mechanisms, so it doesn’t work for every patient.”
The artificial urinary sphincter (AUS) has classically been the best option for men with more significant incontinence who either still have bad leakage after a sling, also underwent radiation, or already leak so much that a sling won’t be enough.
“This is a three-piece implant where we put a man-made sphincter around the urethra,” Sury explained. “It looks just like a tiny blood pressure cuff and inflates to close off the urethra. This device does not rely on your natural sphincter function at all, so it is a great option for all severities of incontinence. However, it is more of an active system. We hide a water balloon in the belly and a small pump in the scrotum, and men squeeze this to open the sphincter when they want to go.”
New treatment option
A new treatment called ProACT is an implant that helps to manage urinary incontinence from prior prostate surgeries. ProACT is the brand name for adjustable continence balloons. They’ve been used for more than 20 years in Europe but only in the United States for the past decade through ongoing Food and Drug Administration studies and research.
Rather than encircling the urethra and squeezing it closed, a balloon is placed on either side of the urethra to apply compression. It is almost like putting the prostate back – a bulky object to passively block the flow, like a dam.
“This is a passive device like the sling, and men do not have to do anything when they want to urinate,” Sury said. “But unlike the ‘set it and forget it’ of a sling, this is ‘set it and adjust it.'” Doctors place the balloons initially with a small amount of fluid, let the patient heal, then see them back in the office every month to add more fluid to the balloons through small titanium ports hidden in the scrotum.
“The idea is to fill them to the sweet spot where they are blocking the urethra enough to keep men dry, but not too much, so they can just void naturally without doing anything like they used to before the prostate was removed,” Sury said. “It’s a longer process to get there with the monthly adjustments, but unlike the sling, if you are not dry to start, we have the opportunity to adjust it and get you there.”
All three surgical options are outpatient, same-day surgeries, and ProACT is inserted through two small holes using a combination of X-ray and cameras. ProAct is now in the national urology guidelines as an option for men with any level of post-prostate surgery incontinence with no history of radiation.
“I think the sling and AUS will continue to be top choices, but in particular, this is a great option for the man who may be leaking too much for a sling, but wants to try this before an AUS,” said Sury. “There is no one-size-fits-all answer to incontinence, and I do a multi-step evaluation of leakage to make sure I guide the patient toward the right choice for them.”