Experience of 5 years adjustable continence therapy (ProACT): the surgical learning curve and patient outcomes

Post-prostatectomy urinary incontinence (PPI) significantly impacts quality of life. While an artificial urinary sphincter is the standard surgical treatment for PPI, adjustable continence therapy balloons (ProACT) have emerged as a less invasive alternative over the past two decades. ProACT implantation is considered technically challenging and limited to three high-volume Dutch medical centers, yet little is known about the surgical learning curve. This study aims to assess the learning curve to inform training requirements for ProACT implantation.

This retrospective single-center study included all ProACT implantations performed by one urologist at Erasmus University medical Center, Rotterdam. Surgery success was defined as postoperative use of a maximum of one 'safety pad', less than 10 mL urine loss or ≥ 95% subjective improvement of continence. Multivariable logistic regression assessed the learning curve.

A total of 108 surgeries between 2019 and 2024 were included, of which 15 were supervised by an experienced surgeon. No statistical relation was found between the progressive surgeon's experience and surgical success (per 10 surgeries, OR 0.89, 95%CI: 0.75-1.07, p = 0.2). Preoperative incontinence (pads/day) was statistically significantly associated with surgical success (OR 0.65, 95%CI: 0.47-0.89, p = 0.009). The overall surgical success rate was 61%, with an additional 20% achieving > 50% continence improvement. Complication rate within six months was 21% of which six (5.6%) included explantations of the ProACT device.

ProACT implantation achieves consistent outcomes after brief supervised training, with no statistically significant learning curve. This supports a broader adoption of this technique by urologists treating PPI.