EURURO Vol. 72 No. 3

It is our consensus that types 2 and 3 (microporous,

10 microns, mono- and multifilament) and type 4

(submicronic and monofilament) are not appropriate for

use in this clinical context.

When considering risk factors for mesh materials, it is

important to consider the following important issues:

1. Overall surface area of the material used (which is

greater for POP than for SUI)

2. Mesh design (eg, physical characteristics of the mesh,

size of the pore as a predisposing factor to infection—in

particular with a pore size of

75 microns)

3. Material (biocompatibility, long-term stability, flexibili-

ty, elasticity, etc.)

The factors influencing the surgical outcomes are as

follows:

1. Indication for which the material is used

2. Overall surface area of the material used (lower overall

surface area for SUI than for POP)

3. Material characteristics (polymer used, physical char-

acteristics of the mesh, size of the pores, surface area,

biocompatibility, long-term stability, compliance)

4. Route of implantation (eg, vaginal or transabdominal)

5. Patient characteristics (eg, somatic inflammatory disease,

obesity, smoking)

6. Associated procedures (eg, hysterectomy)

7. Surgeon experience

There is a lack of both preclinical and real-life practice

clinical data. Whilst there are randomised controlled

studies, the majority are limited in terms of the number

of recruited individuals and duration of follow-up, and they

do not evaluate differences in product design.

It is clear that:

1. The risk of use of a mesh increases with its surface area

and, thereby, its increasing density.

2. In this context, a clear distinction should be drawn

between the tape used for synthetic MUSs and the larger

amount of mesh used to treat POP. A significantly greater

amount of mesh is implanted in patients with POP than

in those with SUI.

3. Surgeons should be adequately experienced in the

management of SUI and POP, and should have all the

therapeutic options available (or be able to refer to

colleagues if required). Patients should be appropriately

assessed and counselled prior to making a decision to

undergo surgery, regarding the experience of the

surgeon and results of the proposed technique.

4. There is higher mesh-associated morbidity when treat-

ing patients with POP as compared with using synthetic

MUSs for SUI.

5. The efficacy and use of synthetic MUSs for SUI is evident,

and it can be recommended for use in clinical practice,

whilst acknowledging the limitations of existing long-

term data and under-reporting of other studies relating

to long-term follow-up in real-life clinical practice.

6. Synthetic MUSs are now the most widely used surgical

approach for SUI with well-established success rates and

safety profile. The efficacy is higher than colposuspen-

sion and comparable with autologous slings, but with

lesser morbidity compared with colposuspension. Mor-

bidity is uncommon, but may occur either at the time of

implantation (eg, bladder perforation or vascular/bowel

injury) or subsequently (eg, tape exposure, pain, or

erosion into the urinary tract). Existing data do not allow

reliable quantification of tape-specific long-term risks,

but it may be 4%

[57]

7. Vaginally implanted mesh for POP is associated with

increased risks. Its use should be restricted to the special

group of patients defined according to established

evidence-based clinical guidelines or in the context of

ethics committee-approved clinical research. Its use

should also be restricted to expert individuals working in

specialised departments. Whilst the risk associated with

the transabdominal insertion of mesh for POP is

considered more acceptable, its use should also be

restricted to specialist practice.

8. Based on the available scientific evidence, the SCENIHR

[21]

recommends the following:

(a) Implantation of any mesh for the treatment of POP

via the vaginal route should only be considered in

complex cases, in particular after failed primary

repair surgery.

(b) Owing to increased risks associated with the use of

synthetic mesh for POP repair via a transvaginal

route, this option should only be used when other

surgical procedures have already failed or are

expected to fail.

procedures where possible. However, there is a need

for further improvement in the composition and

design of syntheticmesh, inparticular for POP surgery.

(d) A certification system for surgeons should be

introduced based on existing international guide-

lines and established in cooperation with the

relevant European Surgical Associations.

(e) Appropriate patient selection and counselling are of

paramount importance for the optimal outcome for

all surgical procedures, particularly for the indica-

tions discussed. This should be based on the results

of further clinical evidence, which should be

collected in a systematic fashion for all these devices.

9. Therapy should only be instituted in accordance with

EAU guidelines and with full informed consent of all

patients.

Treatment of SUI in men

Physiotherapy is considered to be better than no treatment

at all, as it is suggested that patients should not undergo

surgery for stress SUI for at least 6 mo and preferably not

before 1 yr after initial surgery. In addition, it is important to

exclude the presence of an anastomotic stenosis and

bladder dysfunction in cases of postradical prostatectomy

prior to considering any corrective surgery.

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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