Importance of cosmesis to patients undergoing renal surgery: a comparison of laparoendoscopic single-site (LESS), laparoscopic and open surgery
Jeffrey A. Cadeddu, Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, J8.106, Dallas, TX 75390-9110, USA. e-mail address: Jeffrey.firstname.lastname@example.org
Study Type – Therapy (case series)
Level of Evidence 4
What's known on the subject? and What does the study add?
Studies in other surgical populations have found that scarring is a relatively unimportant preoperative patient consideration when compared with surgical cure and safety, but that younger age was a significant factor influencing preference for ‘scarless’ surgery.
The present study corroborates the findings of previous series, among patients who were contemplating kidney surgery.
- • To evaluate patient attitudes towards cosmesis relative to other considerations, before and after undergoing laparoendoscopic single-site surgery (LESS) vs laparoscopic/robot-assisted vs open kidney surgery.
- • Participants were provided with a survey querying demographic information, surgical history and importance of scarring relative to other surgical outcomes and considerations.
- • The relative importance of each outcome was recorded on a nine-level ranking scale, ranging from 1 (most important) to 9 (least important).
- • The median scores for each outcome were compared before and after surgery using the Wilcoxon signed-rank test, and by surgical approach using the Kruskal–Wallis test.
- • The importance of scarring was further analysed according to age (≤50 vs >50 years), surgical indication (oncological vs non-oncological), gender, and proportion of patients who had undergone previous abdominal surgery.
- • A total of 90 patients completed surveys before surgery, of whom 65 (72.2%) also completed surveys after surgery.
- • ‘Surgeon reputation’ and ‘no complications’ were the most important considerations before surgery (median scores 2 and 3, respectively) and after surgery (median scores of 2 for both).
- • ‘Size/number of scars’ was the least important consideration before surgery (median score 8) and the second least important consideration after surgery (median score 7).
- • The median score for ‘size/number of scars’ was significantly higher for the LESS cohort before surgery (laparoscopic/robot-assisted vs LESS vs open surgery: 8.5 vs 6 vs 9; P = 0.003), but was nonsignificant after surgery (laparoscopic/robotic vs LESS vs open surgery: 7 vs 6.5 vs 7.5; P = 0.83).
- • The median score for ‘size/number of scars’ before surgery was significantly higher for younger patients (P = 0.05) and those with non-oncological surgical indications (P < 0.001), but there was no significant difference in this outcome for these sub-groups after surgery.
- • For most patients contemplating urological surgery, cosmesis is of less concern than surgeon reputation and avoidance of surgical complications.
- • Cosmesis may be a more important preoperative consideration for younger patients and those with benign conditions, which warrants further investigation.
Advanced laparoscopic procedures are increasingly used in the surgical management of a wide variety of urological conditions. Laparoendoscopic single-site (LESS) surgery, where abdominal access is gained through a single abdominal incision as compared with the 3–5 incisions required for conventional laparoscopy, is the most recent evolution in minimally invasive urology. LESS urological procedures were first reported in 2007 [1,2], and have since gained popularity among some urologists because of their potential for improved surgical morbidity, convalescence and cosmesis. Comparative series to date have reported the feasibility, safety, equivalent perioperative and short-term surgical outcomes, and superior cosmesis for LESS as compared with conventional laparoscopy [3–7]; however, reported cosmesis outcomes for LESS have been based on subjective surgeon assessment rather than objective measurement [4,5,7]. Furthermore, attitudes towards cosmesis as a consideration among patients contemplating urological surgery are unknown.
Cosmesis is a significant issue in certain surgical populations; Dunker et al.  published a study comparing open vs laparoscopic ileocolic resection for Crohn's disease with regard to differences in body image perception and cosmetic satisfaction. Body image and cosmesis were assessed using scaled questionnaires, with a single composite score generated for each of these domains. The cosmetic score was found to be significantly higher for the laparoscopic surgery cohort, while the body image score was not significantly different between the groups. In addition, the authors evaluated the patients' hospital experiences after surgery, using a ranking scale to assess the relative importance of factors such as absence of complications, size/number of scars, surgeon reputation and others. ‘No complications’ was ranked as the most important factor, while ‘size of the scar’ was relatively unimportant; however, scar size was found to be a more important consideration for patients undergoing surgery than for those treated conservatively .
In the present study, we used a similar methodology to evaluate the importance of scarring in urology patients relative to other surgical outcomes, comparing results for LESS vs laparoscopic vs open surgery. The primary objective of the present study was to assess the previously unknown relative importance of cosmesis to patients undergoing kidney surgery, and to determine whether this differed for patients undergoing LESS vs laparoscopic vs open surgery.
After institutional review board approval, consecutive patients scheduled for kidney surgery at our institution were recruited for the study and informed consent was obtained from each participant. The study period was August 2009 to June 2010. A single surgeon performed all preoperative counselling and surgery. Participants were provided with a brief survey querying demographic information, surgical history and importance of scarring relative to other surgical outcomes and considerations (Appendix A). Surveys were completed before and after surgery, with preoperative surveys completed during the initial clinic visit or just before surgery, and postoperative surveys ≥3 months after surgery, either during follow-up clinic visits or by post. The relative importance attributed to each outcome was recorded on a nine-level ranking scale, with a score of 1 representing the highest, and 9 representing the lowest rank. Scores for ‘size/number of scars’ were further analysed after stratification by age, gender, surgical indication and history of previous abdominal surgery.
Median scores for each outcome were compared before and after surgery using the Wilcoxon signed-rank test. Postoperative median scores for ‘size/number of scars’ for each surgical approach were compared using the Kruskal–Wallis test, with post-hoc analyses performed using the Mann–Whitney U-test as needed. Continuous demographic variables were compared using one-way avova. A P value of ≤0.05 was considered to indicate statistical significance. Analyses were run using the StataTM version 10 statistical software package (StataCorp LP, College Station, TX, USA).
In all, 90 patients completed surveys before surgery, of whom 65 (72.2%) also completed surveys after surgery. The mean (sd) patient age was 51.1 (15.1) years. Of the 90 patients, 40 (44.4%) were male, 56 (62.2%) had a history of previous abdominal surgery, and 65 (72.2%) underwent surgery for oncological indications. The kidney surgeries consisted of nephrectomy, partial nephrectomy, pyeloplasty or cyst decortications. The surgical cohorts were similar with regard to gender and race distributions, as well as proportion who had undergone previous abdominal surgery (Table 1), but the LESS cohort was younger (P = 0.015), and more likely to be undergoing surgery for benign indications (P < 0.001).
Table 1. Patient characteristics
|Mean (sd) age||53.1 (14.7)||43.3 (14.4)||53.8 (14.0)||51.1 (15.1)|
|Race, n (%)|
| White||37 (72.6)||18 (78.3)||12 (75)||67 (74.4)|
| Non-white||14 (27.4)||5 (21.7)||4 (25)||23 (25.6)|
|Surgical indication, n (%)|
| Oncological||42 (82.4)||7 (30.4)||16 (100)||65 (72.2)|
| Non-oncological||9 (17.7)||16 (69.6)||0 (0)||25 (27.8)|
|Previous abdominal surgery, n (%)||35 (68.6)||12 (52.2)||9 (56.3)||56 (62.2)|
Before surgery, the most important surgical consideration was ‘surgeon reputation’ (median score 2), while the least important were ‘delay in resuming normal diet’ and ‘size/number of scars’ (both with median scores of 8). After surgery, the most important considerations were ‘surgeon reputation’ and ‘no complications’ (both with median scores of 2), while ‘size/number of scars’ was the second least important consideration (median score 7 [Table 2]). Among the subset of patients who completed surveys both before and after surgery, there was no significant change in median scores after surgery compared with those before surgery for any of the outcomes except ‘duration of hospital admission’ (P = 0.007).
Table 2. Patient preferences and considerations for surgery listed in order of importance
|Reputation of surgeon||2 (1–8)||2 (1–8)|
|No complications||3 (1–9)||2 (1–9)|
|Surgeon recommendation||3 (1–9)||4 (1–9)|
|Pain after surgery||4 (1–8)||4 (1–8)|
|Reputation of hospital||4 (1–9)||5 (1–9)|
|Delay in resuming normal activity||6 (2–9)||7 (2–9)|
|Duration of hospital admission||7 (1–9)||6* (1–9)|
|Size/number of scars||8 (1–9)||7 (3–9)|
|Delay in resuming normal diet||8 (3–9)||8 (3–9)|
The median score for ‘size/number of scars’ was significantly higher for the LESS cohort before surgery (P = 0.003), but there was no significant difference among the cohorts after surgery (P = 0.83 [Table 3]). When data for the overall cohort were analysed by age (≤50 vs >50 years), gender, surgical indication (oncological vs non-oncological) and history of previous abdominal surgery (none vs any), the median postoperative score for ‘size/number of scars’ did not differ significantly for younger patients, females, those undergoing surgery for non-oncological indications or those with no previous history of abdominal surgery; however, the median preoperative score for ‘size/number of scars’ was significantly higher for younger patients (P = 0.05) and those with non-oncological surgical conditions (P < 0.001 [Table 4]).
Table 3. Analysis of scar importance by surgical approach
|Median (range) score before surgery||8.5 (1–9)||6 (1–9)||9 (4–8)||0.003|
|Median (range) score after surgery||7 (3–9)||6.5 (3–9)||7.5 (5–9)||0.83|
Table 4. Analysis of importance of scar according to age and surgical indication
|Median (range) score before surgery||7 (1–9)||9 (1–9)||0.05|
|Median (range) score after surgery||9 (3–9)||7 (3–9)||0.16|
|Median (range) score before surgery||9 (1–9)||6 (1–9)||<0.001|
|Median (range) score after surgery||7 (3–9)||9 (4–9)||0.25|
The last two decades have witnessed an exponential increase in the use of urological laparoscopy, largely because of improved operative morbidity and convalescence while maintaining the efficacy of open surgery [9,10]. Continued interest in further improving surgical outcomes by minimizing invasiveness has led to the development of advanced laparoscopic procedures such as LESS surgery. To date, published reports have not identified a clear benefit of LESS over conventional laparoscopy [3–7] except, subjectively, for cosmesis [4,5,7]; however, patient preferences for cosmesis relative to other perioperative outcomes after urological surgery are unknown. In addition, objective quantitative assessment of cosmesis outcomes after LESS vs laparoscopic vs open urological surgery has not hitherto been reported.
In the present study, we found that, when compared with surgeon reputation or avoidance of complications, surgical scarring was a relatively unimportant outcome for most patients before and after undergoing kidney surgery. Younger patients and those undergoing surgery for benign indications, who made up a significant proportion of the LESS cohort, ranked scarring higher than older patients and those with oncological indications before surgery, but these differences were nonsignificant after surgery. The present findings suggest that after the experience of surgery, safety and uneventful perioperative recovery were the most important considerations for most patients, regardless of the surgical approach used. ‘Surgeon reputation’ may be viewed as a surrogate for patient confidence in the expectation of a safe operation, as patients seem to associate surgical acumen with surgical safety.
The present findings are similar to those of Bucher et al. , who conducted a survey of attitudes towards surgical outcomes and cosmesis amongst medical and paramedic staff, patients undergoing abdominal visceral surgery, and the general public. They found that, for the majority of respondents across these groups, considerations before surgery in order of importance were surgical cure, safety and scarring. Indeed, 93% of patients and 91% of the general public would accept a larger scar if surgical risks were lower; however, assuming equal surgical risks for LESS, conventional laparoscopy or natural orifice translumenal endoscopic surgery (NOTES), 75% of respondents would still opt for the LESS approach, and with a doubling of the risk for LESS surgery relative to conventional laparoscopy, 37% of respondents would still opt for the LESS approach .
The results of the present study, as well as the findings of Bucher et al. , suggest that global assumptions cannot be made about which surgical considerations are important to patients. In the present study, younger patients and those undergoing surgery for benign indications ranked scarring significantly higher than older patients or those with malignant conditions before surgery. Similarly, Bucher et al.  found that preference for scarless surgery was influenced by younger age, but not by gender, education, medical history or profession. These combined findings not only underscore the importance of pursuing improvements in the technique and safety of LESS surgery, but also of the need for further research efforts on patient and public perceptions towards emerging surgical techniques, before more widespread adoption can be expected.
We acknowledge a few limitations in this first study of attitudes towards cosmesis among urology patients. Firstly, patient attitudes were studied after the decision to proceed with surgery by a particular approach had been reached. As such, although this is a prospective study, patient responses are likely to have been partly biased by the pre-surgical counselling received; however, by re-evaluating patient attitudes after surgery, we believe that the degree of this bias was reduced, as evidenced by a shift in preferences more strongly in favour of avoidance of complications. Although a future randomized trial comparing these surgical approaches with regard to similar outcomes would be of value, this is the first study evaluating patients' perceptions of the importance of scarring relative to other surgical outcomes. Secondly, it is important to recognize that LESS procedures are still in their clinical infancy, and as such, comparisons with well established open or laparoscopic techniques are necessarily limited. With further improvements in technique, instrumentation and safety, and with increasing recognition by patients, its role in specific patient populations can better be elucidated. Despite these limitations, it is important to emphasize the importance of research efforts into patient attitudes towards new techniques and technologies, as they are an important component of forces external to the clinical environment that can have a significant impact on the adoption of new procedures .
In conclusion, for most patients contemplating urological surgery, cosmesis is a lesser concern than surgeon reputation and avoidance of surgical complications, but cosmesis may be a more important surgical consideration among younger patients and those with benign conditions, and this warrants further investigation. Efforts are currently underway to quantitatively assess the value of cosmesis as a postoperative outcome among urology patients.
CONFLICT OF INTEREST
APPENDIX A: DEMOGRAPHICS AND RANKING THE IMPORTANCE OF PREOPERATIVE PARAMETERS
- 1How old are you: ____
- 2What is your gender? (please circle one):
- 3Have you had any previous abdominal surgery or scars on your abdomen? (please list)
- 4How important are the following factors in your decision to have your surgery performed? Please rank the following in terms of how important they are for you in the period before your surgery:
____ Duration of hospital admission
____ Size of scar or number of scars
____ No complications
____ Pain after surgery
____ Delay in resuming normal daily activities
____ Delay in resuming normal diet
____ Reputation of hospital
____ Reputation of surgeon
____ Surgeon recommendation