EURURO Vol. 72 No. 3

Introduction

If lifestyle interventions, pelvic floor muscle training

(PFMT), pessary treatment, and drug therapy for stress

urinary incontinence (SUI) and pelvic organ prolapse (POP)

are unsuccessful, the surgeon may have to decide whether

to use a surgical approach. For SUI and POP surgery,

biological grafts derived from either xenograft or allograft

materials and autologous tissue are alternatives to synthet-

ic tapes/meshes. Current evidence would not support the

use of nonautologous biological materials, whether of

human or animal origin. Nonabsorbable synthetic polypro-

pylene (PP) tapes/meshes have widely been used and other

materials to a lesser extent. Aspects that need to be carefully

considered are the filamentous structure (mono- or

multifilament) and its pore size, surface area, textile

properties, and type of polymer used. Postimplantation

changes linked to biomechanics and host response are likely

to influence the clinical outcomes, but implantation

techniques, surgeon experience, and patient risk factors

are equally important contributing factors.

Patient stratification based on careful assessment

according to contemporary guidelines is essential, as are

adequate identification of the patient’s goals and expecta-

tions, counselling of patients, collaborative decision mak-

ing, and appropriate surgeon experience and expertise. The

group highlights that the ultimate aim of any surgical

treatment for non-life–threatening conditions is to improve

the patient’s quality of life.

In view of current controversies relating to the use of

implanted materials for SUI and POP, and the lack of clear

guidelines for the use of biomaterials, the European

Association of Urology (EAU) and European Urogynecolo-

gical Association (EUGA) convened this expert group to

discuss the evidence relating to current practice in this area

of functional urology and urogynaecology. The conclusions

from the group are presented in this consensus statement.

The clinical problem

Pelvic floor dysfunction is a major health problem for many

women, and SUI affects an estimated one in three women

and POP affects an estimated one in nine women

[1]

. It is

strongly linked to childbearing

[2]

, obesity, and advancing

age, and it is not surprising that there has been an increase

in the lifetime risk that a woman will undergo a surgery for

SUI and POP, from 11% in 1997 to 19–20% at present

[3,4]

. A

Norwegian study

[5]

reported the percentage of patients

with SUI to be approximately half of all women with

incontinence, with the remainder characterised as urgency

(11%) and mixed incontinence (36%). In a large observa-

tional cohort study, anatomical prolapse stage 2 or higher

was observed in more than one of two women 12 yr after

first delivery

[6]

. In another study, 24% of prolapses

protruded beyond the hymen, a point where most women

become symptomatic

[7] .

The lifetime risk for parous

women to undergo at least one surgical treatment for either

SUI or POP is 1:10

[8]

. With surgical repair using native

tissue there is a failure rate for primary repair of POP of

approximately 17–20% in 10 yr

[9]

. This has resulted in the

adoption of mesh-augmented prolapse repair.

POP is less commonly seen in male patients, and SUI is

usually seen only as a consequence of surgery on the

prostate—usually after radical prostatectomy for prostate

cancer, where percentages up to 31% are reported

[10]

, or

intervention albeit far less commonly for benign prostatic

obstruction.

Treatment of SUI in women

PFMT/physiotherapy is usually considered to be an effective

treatment for mild to moderate SUI in the short to medium

term and certainly is more effective than no treatment. One

large multicentre randomised controlled trial (RCT) com-

pared PFMT/physiotherapy and synthetic midurethral-sling

the use of polypropylene (PP) materials used for the treatment of SUI and POP, with

reference to the 2016 EAU guidelines (European Association of Urology 2016), the European

Commission’s SCENIHR report on the use of surgical meshes (SCENIHR 2015), other

available high-quality evidence, guidelines, and national recommendations.

Evidence synthesis:

Current data suggest that the use of nonautologous durable materials

in surgery has well-established benefits but significant risks, which are specific to the

condition and location they are used for. Various graft-related complications have been

described—such as infection, chronic pain including dyspareunia, exposure in the vagina,

shrinkage, erosion into other organs of xenografts, synthetic PP tapes (used in SUI), and

meshes (used in POP)—which differ from the complications seen with abdominal herniae.

Conclusions:

When considering surgery for SUI, it is essential to evaluate the available

options, which may include synthetic midurethral slings (MUSs) using PP tapes, bulking

agents, colposuspension, and autologous sling surgery. The use of synthetic MUSs for

surgical treatment of SUI in both male and female patients has good efficacy and acceptable

morbidity. Synthetic mesh for POP should be used only in complex cases with recurrent

prolapse in the same compartment and restricted to those surgeons with appropriate

training who are working in multidisciplinary referral centres.

Patient summary:

Synthetic slings can be safely used in the surgical treatment of stress

incontinence in both male and female patients. Patients need to be aware of the alternative

therapy and potential risks and complications of this therapy. Synthetic mesh for treating

prolapse should be used only in complex cases with recurrent prolapse in specialist referral

centres.

Keywords:

Mesh

Stress urinary incontinence

Pelvic organ prolapse

Consensus statement

E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 4 2 4 – 4 3 1

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