The aim of the study was to confirm the feasibility of tendon transplantation for minimally invasive genital sacropexy in a multi-center setting. The technique was introduced in 2018. Meanwhile patients know the discussion about synthetic meshes and ask for alternative materials. The technique was electronically published in June 2019 [1]. Meanwhile a semitendinosus tendon was used for a minimally-invasive pectopexy as well and even instead of a synthetic TVT mesh [2,3]. The results are comparable to synthetic meshes and therefore we do almost all these operations by using a tendon instead.

In this study patients with uterine or vaginal vault prolapse (POP-Q point C stage 2-4) were offered a laparoscopic sacropexy by means of autologous semitendinosus tendon transplantation. This study presents a multi-center feasibility trial regarding the first 21 patients who underwent surgery with this technique. 
After preparing the vagina, cervix or uterus for laparoscopic sacropexy the tendon of the patient's semitendinosus muscle was removed and brought intraabdominally through the 10mm trocar. The tendon was fixed to the vagina, cervix or uterus, put through the longitudinal ligament above L5/S1 after tunneling and led back to the structure that has to be fixed.
All patients were asked to fill out the german version of the KOOS questionnaire for evaluating the knee functioning before the operation, 6 weeks and 6 months after the operation. 
The detailed study protocol was approved by a university ethic committee and registered in the German Clinical Trials Register. Written informed consent was obtained from all patients.

All operations were performed successfully without intraoperative complications. Recovery was fast, and discharge was possible between the first and forth postoperative day. In 16 patients a cervicosacropexy was done, in 3 patients the vaginal vault was fixed and in 2 patients a hysteropexy was performed. Mean duration of the operation was 2h11m (1h28m-3h53m); mean duration of tendon stripping was 12minutes (8m-23m). Mean age of the patients was 59 (48-72). The mean BMI of the operated patients was 25 (22-30). 
Vaginal examination after 6 weeks and 6 months demonstrated the intended elevation of the middle compartment (mean POP-Q point C 0). The mobility and the power of the affected leg did not change. The KOOS questionnaire after 6 weeks and 6 months describing the leg functioning showed no significant changes compared with the findings before the tendon stripping.

Our approach demonstrates the feasibility and safety of a laparoscopic sacropexy with a semitendinosus autograft instead of a synthetic mesh in a multi-center setting. The operated patients were satisfied with the postoperative results until the 6 months follow-up. 
The experience from orthopedic surgery shows that a semitendinosus tendon autograft is long-lasting and stable and the morbidity on the operated leg is low. As it is just the combination of two established procedures (tendon transplantation, sacropexy) we see potential that it might become an alternative material for the controversial and, in some countries, already banned synthetic meshes.

Hamstring Autograft as a Mesh Alternative for Pelvic Organ Prolapse. Hornemann A, Hoch B, Germann G, Franz W, Sütterlin M. J Minim Invasive Gynecol. 2020 Jan;27(1):17-18. doi: 10.1016/j.jmig.2019.05.018. Epub 2019 Jun 5.
Tendon incontinence repair - First experience with an autologous semitendinosus tendon transplant for urinary stress incontinence treatment. Hornemann A, Hoch B, Franz W, Sütterlin M. Urol Case Rep. 2020 May 21;32:101257. doi: 10.1016/j.eucr.2020.101257. eCollection 2020 Sep.
Tendon Descensus Repair (TENDER) - A prospective clinical feasibility study of tendon transplantation for pelvic organ prolapse repair. Hornemann A, Hoch B, Hofmann J, Franz W, Sütterlin M. Eur J Obstet Gynecol Reprod Biol. 2020 Jun;249:37-41. doi: 10.1016/j.ejogrb.2020.04.035. Epub 2020 Apr 18.