Does Incision Location Matter? Analysis of Single-Port Cosmesis in Urologic Reconstructive Surgery

Abstract

Introduction and Objective:

One potential advantage of single-port (SP) robotic surgery compared with multiport (MP) robotic surgery is improved cosmesis. The only studies in urology patients to suggest this finding did not assess differences based on incision site. Our study evaluated SP, MP, incision location, age, gender, and prior abdominal surgery as predictors of cosmesis and scar consciousness for reconstructive procedures.

Methods:

This is a cohort study using an institutional review board–approved prospective genitourinary reconstruction database. Patients at least 3 months from surgery were emailed and called to complete the Consciousness subsection of the Patient Scar Assessment Questionnaire. Bothersome was defined as a score of 11 or greater. Overall consciousness was scored with a single item as “not conscious” or “conscious.” Pearson’s chi-squared, Wilcoxon rank sum, Fisher’s exact test, and logistic regression were performed to assess how age, gender, prior surgery, and incision location affect cosmesis.

Results:

There were 111 patients (54 MP, 57 SP), of which 27 were SP umbilical, 14 were SP midline nonumbilical, and 16 were SP lower quadrant. On univariate analysis the periumbilical incision had the lowest consciousness. Age was associated with Bother (p = 0.012) and Consciousness (p = 0.002), whereas gender, prior abdominal surgery, and incision site were not significant. On logistic regression, all SP incisions were less likely to be bothered compared with MP, although only SP umbilical was statistically significant (odds ratio [OR] = 0.08, 95% confidence interval [CI]: 0.01,0.38; p = 0.005). Age was also significant on logistic regression for Bother (OR = 0.96, 95% CI: 0.93,0.99; p = 0.005). Gender and prior abdominal surgery were not associated with Bother or Consciousness.

Conclusions:

SP periumbilical incisions provide the best outcomes for cosmesis compared with other SP incision sites and MP incisions. This finding should be discussed and taken into account when planning surgical approaches for patients undergoing urinary reconstruction, especially in patients younger than 40 years of age.

Introduction

Since its introduction in 2018, the da Vinci single port (SP) has been utilized for a variety of urologic surgeries, including partial nephrectomy, radical/simple prostatectomy, urinary tract reconstructions, and radical cystectomy.^1,2 Several potential advantages of the SP compared with multiport (MP) include shorter length of stay, decreased postoperative opioid use, and improved cosmesis.^3

–6 While cosmesis is a secondary objective compared with primary surgical outcomes of success and postoperative recovery, it has been suggested as a priority for younger patients.⁷ Efforts to improve cosmesis have resulted in changed incision placement in patients undergoing urologic reconstructive surgery.⁸ Scar appearance and visibility have been shown to influence the preferred surgical approach by patients in urology and other surgical fields.^9,10 Park et al. showed that patients preferred single-incision kidney surgery compared with open or traditional laparoscopic surgery for cosmetic outcomes assuming an equivalent surgical risk.⁷

Numerous studies have suggested that SP incisions in urologic surgery have improved cosmesis, but these reports have not directly assessed the cosmesis of different SP incision sites as an outcome.^{3,8,11

–14} When cosmesis is measured, there is no uniform and accepted measurement, with reports often not including validated instruments. A prior systematic review comparing minimally invasive and open kidney surgery was unable to conclude about cosmesis because of variable reporting methods, despite identifying eight different studies that included an assessment of cosmesis.¹⁵

Two prior studies have utilized validated patient-reported outcome measures to objectively measure cosmesis outcomes in patients undergoing urologic surgery with SP. Neither of these studies was in patients undergoing reconstructive urologic surgery nor investigated the impact of SP incision location on cosmesis.^5,6 Several different SP incision sites have been reported for patients undergoing urologic surgery, such as the periumbilical, mini-Pfannenstiel, and lower anterior access incision.^3,16 The periumbilical incision is used exclusively with a transperitoneal approach. In contrast, the midline nonumbilical incision can be used with either a transperitoneal or extraperitoneal/transvesical approach.¹⁷ The lower anterior access can be used with a transperitoneal or retroperitoneal approach to the kidney and ureter.¹⁶ It is unclear whether there are differences in cosmetic outcomes with the various SP incision sites that have been introduced. In addition, as these studies were in the context of oncologic procedures, patients may have prioritized cosmetic outcomes less. The assessment of cosmesis of different SP incisions for patients who underwent robotic procedures for benign disease is not reported in the literature despite suggestions that these patients may value cosmesis more than those who underwent surgery for oncologic indications.⁷

We report the cosmetic outcomes of SP incisions compared with MP, and whether age, gender, and prior abdominal surgery influence patient scar consciousness. Since cosmesis has been suggested to be a priority for patients with benign disease, the focus of the study was patients who underwent benign reconstructive surgery. This is the first report in the literature to objectively measure cosmetic outcomes between different SP incision sites and MP incisions in adult patients who underwent reconstructive urologic procedures.

Patients and Methods

Study population

We performed a retrospective review of our institutional review board–approved, prospectively maintained database for patients who underwent reconstructive urologic surgery. Inclusion criteria were English-speaking patients, a minimum of 18 years old, undergoing surgery for benign urologic disease with either the da Vinci MP or SP, with a minimum of 3 months from surgery.

A total of 257 patients were initially identified in our database undergoing urologic reconstructive surgery from December 2017 to October 2023, and from this group, 14 patients were excluded for not having English as a primary language, 7 were deceased, and 5 were less than 3 months from surgery. Of the remaining 231 patients, 111 completed the Consciousness subsection of the Patient Scar Assessment Questionnaire for a response rate of 48.05%. Patients were emailed and called up to five times to complete the questionnaire.

Surgical incision classification

Patient incisions were classified as MP, SP umbilical, SP midline nonumbilical, and SP lower quadrant based on a review of the incision in patient records. Midline nonumbilical was used as a category for incisions placed directly above or below, but not at the umbilicus. The decision to utilize an assistant port with an additional incision for SP was recorded. The rate of postoperative hernia requiring surgery for the most commonly used SP incision, periumbilical, was recorded from follow-up. Examples of SP lower quadrant, midline nonumbilical, and SP umbilical are provided in Figure 1, Figure 2, and Figure 3, respectively.

FIG. 1.

A picture of a lower quadrant incision.

FIG. 2.

A picture of a midline nonumbilical incision.

FIG. 3.

A picture of a periumbilical incision.

Patient Scar Assessment Questionnaire

The Consciousness Domain of the Patient Scar Assessment Questionnaire was utilized to objectively assess cosmesis outcomes. This questionnaire is a validated instrument composed of four separate domains that can be measured separately.⁶ To improve the response rate we elected to focus on the consciousness domain, as this domain was found to be significant in a prior study, and the questions assessed the impact of scar location on body image.⁶ The questionnaire is composed of six items, each scored from 1 (Never conscious/Not at all noticeable) to 4 (Very noticeable/Always conscious) with higher scores indicating worse consciousness. Scores ranged from a minimum of 6 points to a maximum of 24 points.

Cosmesis scores were defined as “Bothered” or “Not Bothered,” with a summed score of <11 being classified as “Not Bothered” and ≥11 being classified as “Bothered,” to reflect a response indicating a minimum of “Sometimes/Slightly noticeable” on the survey.

Consciousness was measured with the summary question assessing overall consciousness, and responses were categorized as either “Not conscious” or “Conscious.” A response of “Not at all self-conscious” on the survey is classified as “Not conscious.” A response of “Slightly self-conscious,” “Fairly self-conscious,” or “Very self-conscious” is classified as “Conscious.”

Statistical analysis

The items on the questionnaire are included in Table 1. We performed Cronbach’s alpha for the survey. Patient characteristics were compared between incision sites of MP, SP umbilical, SP lower quadrant, and SP midline nonumbilical. Pearson’s chi-squared test was performed to compare gender and prior abdominal operations. Fisher’s exact test was utilized to compare percent bothered and percent conscious between incision groups, and between SP with and without an assistant port. Kruskal–Wallis rank sum test was performed to compare the median age at surgery, median months from surgery to survey completion, and the median sum of cosmesis scores between the incision groups.

Table 1.

Consciousness Domain of Patient Scar Assessment Questionnaire

Questionnaire items
How noticeable is your scar to you?
Not at all noticeable(1)	Slightly noticeable (2)	Fairly noticeable (3)	Very noticeable (4)
How noticeable do you think your scar is to others?
Not at all noticeable(1)	Slightly noticeable (2)	Fairly noticeable (3)	Very noticeable (4)
Do you think people ever stare at your scar?
No, never (1)
Yes, people stare	Sometimes (2)	Often (3)	Always (4)
Do you make an effort to try and hide your scar?
No, never (1)
Yes, I try and hide the scar	Sometimes (2)	Often (3)	Always (4)
How often do you think about your scar?
Never (1)	Sometimes (2)	Often (3)	Always (4)
How often do you look at your scar?
Never (1)	Sometimes (2)	Often (3)	Always (4)
Additional summary question on overall consciousness (not included in summed score)
Overall, how self-conscious are you of your scar?
Not at all self-conscious (1)	Slightly self-conscious (2)	Fairly self-conscious (3)	Very self-conscious (4)

Multivariate analysis with logistic regression was performed to compare incision site, age, gender, and prior abdominal operations between patients who were Bothered vs Not bothered and Conscious vs Not conscious. Propensity-Score Matched Analysis was performed with a balance of covariates for prior abdominal surgery and time to questionnaire completion.

Results

Survey reliability and univariate analysis of incision sites

Cronbach’s alpha was 0.83 (Feldt 95% confidence interval or CI: 0.77–0.87), indicating reliability of responses. Of the entire cohort, five patients (4.5%) were noted to have postoperative hernias. Of these, three were treated surgically. The rate of postoperative hernia for SP umbilical requiring surgery was 7.4% (2/27), with an overall hernia rate of 11% (3/27), the highest rate compared with MP and other SP incisions. No patients with SP lower quadrant incisions were noted to have postoperative hernia.

Of the cohort, six patients were recorded as having an assistant port, with five of these patients having SP umbilical incision and one with a midline nonumbilical incision.

The results of the comparison of patient characteristics between different incision sites are listed in Table 2. Of the 111 patients, 54 were MP, 27 were SP umbilical, 14 were midline nonumbilical, and 16 were lower quadrant incisions. History of prior abdominal operations was significantly different between MP (38/54, 70%), SP umbilical (8/27, 30%), midline nonumbilical (6/14, 43%), and lower quadrant (5/16, 31%), p = 0.001. Median months to survey completion were also significantly different between groups: MP 30 (20, 53), SP umbilical 27 (18, 35), midline nonumbilical 34 (21, 43), and lower quadrant 13 (6, 20), p < 0.001. On univariate analysis SP umbilical and midline nonumbilical had lower Bother and Consciousness compared with MP, but this difference did not reach statistical significance despite 7.4% of umbilical incisions being bothered as opposed to 30% of MP incisions.

Table 2.

Comparison of Incision Sites on Univariate Analysis

Characteristic	Overall, N = 111	MP, N = 54	Lower quadrant, N = 16	Midline nonumbilical, N = 14	Umbilical, N = 27	p-Value
Sex, n (%)						>0.99^a
Female	62 (56)	30 (56)	9 (56)	8 (57)	15 (56)
Male	49 (44)	24 (44)	7 (44)	6 (43)	12 (44)
Prior abdominal operations, n (%)						0.001 ^a
No	54 (49)	16 (30)	11 (69)	8 (57)	19 (70)
Yes	57 (51)	38 (70)	5 (31)	6 (43)	8 (30)
Age at surgery, median (IQR)	58 (38–70)	61 (44–70)	57 (33–68)	55 (39–60)	57 (33–70)	0.55^b
Months to completion, median (IQR)	27 (15–42)	30 (20–53)	13 (6–20)	34 (21–43)	27 (18–35)	<0.001 ^b
Bothered, n (%)						0.085^c
Not bothered	86 (77)	38 (70)	11 (69)	12 (86)	25 (93)
Bothered	25 (23)	16 (30)	5 (31)	2 (14)	2 (7.4)
Overall consciousness rating, n (%)						0.45^c
Not conscious	83 (75)	37 (69)	12 (75)	11 (79)	23 (85)
Conscious	28 (25)	17 (31)	4 (25)	3 (21)	4 (15)
Sum of cosmesis scores, median (IQR)	8 (7–10)	9 (7–11)	9 (8–11)	8 (7–10)	7 (6–9)	0.16^b
Postoperative Hernia noted, n (%)						0.14^c
No	106 (95)	53 (98)	16 (100)	13 (93)	24 (89)
Yes	5 (4.5)	1 (1.9)	0 (0)	1 (7.1)	3 (11)
Procedure, n (%)						0.007^c
Bladder neck reconstruction	1 (0.9)	1 (1.9)	0 (0)	0 (0)	0 (0)
Buccal ureteroplasty	14 (13)	11 (20)	0 (0)	0 (0)	3 (11)
Non-refluxing reimplant	1 (0.9)	1 (1.9)	0 (0)	0 (0)	0 (0)
Refluxing reimplant	23 (21)	14 (26)	1 (6.3)	5 (36)	3 (11)
Pyeloplasty	50 (45)	12 (22)	14 (88)	7 (50)	17 (63)
Nephrectomy	7 (6.3)	4 (7.4)	0 (0)	0 (0)	3 (11)
Side-to-side reimplant	5 (4.5)	5 (9.3)	0 (0)	0 (0)	0 (0)
Transureteroureterostomy	2 (1.8)	1 (1.9)	0 (0)	1 (7.1)	0 (0)
Ureteroureterostomy	4 (3.6)	1 (1.9)	1 (6.3)	1 (7.1)	1 (3.7)
Ureterolysis	2 (1.8)	2 (3.7)	0 (0)	0 (0)	0 (0)
Other (cyst decortication, Boari flap)	2 (1.8)	2 (3.7)	0 (0)	0 (0)	0 (0)

Bolded means statistically significant.

Pearson’s chi-squared test.

Kruskal–Wallis rank sum test.

Fisher’s exact test.

IQR, interquartile range; MP, multiport.

Univariate analysis of Bother

The results of the comparison of patient characteristics and Bother are listed in Table 3. Median age at surgery was significantly associated with Bother with incision. Prior abdominal operations and gender were not associated with Bother with incision.

Table 3.

Comparison of Bother on Univariate Analysis

Characteristic	Overall, N = 111	Not bothered, N = 86	Bothered, N = 25	p-Value
Sex, n (%)				0.66^a
Female	62 (100)	49 (79)	13 (21)
Male	49 (100)	37 (76)	12 (24)
Prior abdominal operations, n (%)				0.40^a
No	54 (100)	40 (74)	14 (26)
Yes	57 (100)	46 (81)	11 (19)
Age at surgery, median (IQR)	58 (38–70)	60 (42–71)	48 (35–60)	0.012 ^b
Age over 60, n (%)				0.052^a
Age <60	61 (100)	43 (70)	18 (30)
Age >60	50 (100)	43 (86)	7 (14)
Age over 40, n (%)				0.073^a
Age <40	29 (100)	19 (66)	10 (34)
Age >40	82 (100)	67 (82)	15 (18)
Use of assistant port, n (%)				0.57^c
No	47 (100)	38 (81)	9 (19)
Yes	6 (100)	6 (100)	0 (0)
Months to completion, median (IQR)	27 (15–42)	30 (15–44)	22 (13–28)	0.085^b
Overall consciousness rating, n (%)				<0.001 ^a
Not conscious	83 (100)	75 (90)	8 (9.6)
Conscious	28 (100)	11 (39)	17 (61)

Bolded means statistically significant.

Pearson’s chi-squared test.

Wilcoxon rank sum test.

Fisher’s exact test.

Univariate analysis of Consciousness

The results of the comparison of patient characteristics and Consciousness are listed in Table 4. Median age at surgery was significantly associated with Consciousness of incision. Prior abdominal operations and gender were not associated with Consciousness of incision.

Table 4.

Comparison of Consciousness on Univariate Analysis

Characteristic	Overall, N = 111	Not conscious, N = 83	Conscious, N = 28	p-Value
Sex, n (%)				0.55^a
Female	62 (100)	45 (73)	17 (27)
Male	49 (100)	38 (78)	11 (22)
Prior abdominal operations, n (%)				0.48^a
No	54 (100)	42 (78)	12 (22)
Yes	57 (100)	41 (72)	16 (28)
Age at surgery, median (IQR)	58 (38–70)	61 (44–71)	42 (27–60)	0.002 ^b
Age over 60, n (%)				0.014 ^a
Age <60	61 (100)	40 (66)	21 (34)
Age >60	50 (100)	43 (86)	7 (14)
Age over 40, n (%)				0.005 ^a
Age <40	29 (100)	16 (55)	13 (45)
Age >40	82 (100)	67 (82)	15 (18)
Use of assistant port, n (%)				>0.99^c
No	47 (100)	37 (79)	10 (21)
Yes	6 (100)	5 (83)	1 (17)
Months to completion, median (IQR)	27 (15–42)	28 (16–46)	24 (15–38)	0.35^b
Bothered, n (%)				<0.001 ^a
Not bothered	86 (100)	75 (87)	11 (13)
Bothered	25 (100)	8 (32)	17 (68)
Sum of cosmesis scores, median (IQR)	8 (7–10)	8 (6–9)	12 (9–15)	<0.001 ^b

Bolded means statistically significant.

Pearson’s chi-squared test.

Wilcoxon rank sum test.

Fisher’s exact test.

Logistic regression analysis

The results of logistic regression assessing whether Bother depends on incision site, age, gender, prior abdominal operations, and time to survey completion are listed in Table 5. With MP as a reference, SP umbilical incision was significantly associated with decreased Bother with incision (OR = 0.08, 95% CI: 0.01–0.38, p = 0.005), consistent with 7.4% of umbilical incisions being bothered as opposed to 30% of MP incisions. Midline nonumbilical and lower quadrant were also associated with decreased Bother but were not statistically significant. Older age was associated with decreased Bother with incisions (OR = 0.96, 95% CI: 0.93–0.99, p = 0.005). Gender and prior abdominal operations were not statistically significant for Bother with incisions.

Table 5.

Logistic Regression Analysis for Bother

Characteristic	N	Event N	OR (95% CI)^a	p-Value
Incision site	111	25
MP			Ref.
Lower quadrant			0.34 (0.07–1.46)	0.16
Midline nonumbilical			0.23 (0.03–1.08)	0.092
Umbilical			0.08 (0.01–0.38)	0.005
Age at surgery	111	25	0.96 (0.93–0.99)	0.005
Sex	111	25
Female			Ref.
Male			1.02 (0.34–3.00)	0.97
Prior abdominal operations	111	25
No			Ref.
Yes			0.66 (0.20–2.16)	0.49
Months to completion	111	25	0.96 (0.93–1.00)	0.031

Bolded means statistically significant.Null deviance = 118; Null df = 110; Log-likelihood = −51.1; AIC = 116; BIC = 135; Deviance = 102; Residual df = 104; No. Obs. = 111.

CI, confidence interval; OR, odds ratio.

The results of logistic regression assessing whether Consciousness depends on incision site, age, gender, prior abdominal operations, and time to survey completion are listed in Table 6. Older patients were less likely to be conscious of their incision scar (OR = 0.95, 95% 0.93–0.98, p < 0.001). Periumbilical incision had the lowest consciousness and approached statistical significance (p = 0.051), with location of other incision sites not significant. Prior abdominal operation and gender were also not significant.

Table 6.

Logistic Regression Analysis for Consciousness

Characteristic	N	Event N	OR (95% CI)	p-Value
Incision site	111	28
MP			Ref.
Lower quadrant			0.27 (0.05–1.31)	0.12
Midline nonumbilical			0.40 (0.07–1.71)	0.24
Umbilical			0.23 (0.05–0.92)	0.051
Age at surgery	111	28	0.94 (0.91–0.97)	<0.001
Sex	111	28
Female			Ref.
Male			0.84 (0.28–2.45)	0.75
Prior abdominal operations	111	28
No			Ref.
Yes			2.11 (0.66–7.46)	0.22
Months to completion			0.96 (0.93–0.99)	0.023

Bolded means statistically significant.Null deviance = 125; Null df = 110; Log-likelihood = −54.6; AIC = 123; BIC = 142; Deviance = 109; Residual df = 104; No. Obs. = 111.

Propensity-score matched analysis of Bother and Consciousness

Table 7 includes the results of a propensity-score matched analysis for Bother and Consciousness with a covariate balance of prior abdominal operations and months to questionnaire completion. Increased age at surgery and umbilical incision were associated with decreased Bother and Consciousness with incision, respectively.

Table 7.

Propensity Score-Matched Analysis of Bother and Consciousness

Characteristic	Bothered		Consciousness
Characteristic	OR (95% CI)	p-Value	OR (95% CI)	p-Value
Surgical site
MP	Ref.		Ref.
Lower quadrant	0.38 (0.07–1.73)	0.24	0.25 (0.04–1.11)	0.090
Midline nonumbilical	0.31 (0.04–1.59)	0.20	0.42 (0.07–1.86)	0.28
Umbilical	0.04 (0.00–0.27)	0.006	0.10 (0.02–0.48)	0.009
Age at surgery	0.94 (0.91–0.97)	<0.001	0.93 (0.90–0.96)	<0.001

Bolded means statistically significant.

Discussion

This report compares SP and MP cosmesis with various SP incision sites in patients who underwent benign urologic surgery, a patient population for which cosmetic outcomes are a priority. On logistic regression, SP umbilical incisions were less likely to be bothered compared with MP. This confirms prior findings that a single incision placed at the umbilicus provides better cosmesis, likely because of the minimal visibility of these incisions.^5,6 Morgantini et al. compared responses on the validated Patient Scar Assessment Questionnaire between 104 SP and 78 MP patients for urologic oncology procedures, and found SP periumbilical, described as “virtually scarless,” had improved scar cosmesis compared with MP.⁶ Huang et al. utilized 234 crowd-sourced survey responses comparing SP periumbilical with and without an assistant port, open surgical, and MP incisions for radical prostatectomy with the psychosocial domain of the ScarQ^TM, with SP incisions being ranked as more appealing compared with MP or open incisions.⁵ However, neither of these studies assessed the cosmesis of different SP incision locations.^5,6

Our results suggest that midline nonumbilical and lower quadrant SP incisions were not associated with improved cosmesis compared with MP on both univariate analysis and logistic regression. A prior study has suggested that incisions that are below the belt line are associated with improved cosmesis in pediatric patients; however, our results did not demonstrate this in adults.¹⁸ Garcia-Roig et al. suggested that incisions covered by undergarments have improved cosmesis based on results from a crowd-sourced online survey. Of note, in this study participants initially did not show a strong preference for lower midline incisions, until being shown an additional picture of hypothetical lower midline incisions being covered by clothing.⁹ Our findings provide a real-world experience in cosmetic outcomes of patients who have undergone surgery and do not show significant cosmetic benefits of incisions below the umbilicus.

An umbilical incision limits the surgeon to a transperitoneal approach and may not be ideal in patients with an increased risk of hernia or who have had previous abdominal surgery(ies) where one would benefit from an extraperitoneal approach.¹⁹ In our cohort of patients with a periumbilical incision, we noted a rate of postoperative hernia treated with surgical repair of 7.4% (2/27) and an overall hernia rate of 11% (3/27). In contrast, no patients with lower quadrant incisions were noted to have a postoperative hernia. The rate of postoperative hernia for single-incision surgery at the umbilicus has been previously reported at 8.4%.²⁰ For patients who would benefit from a retroperitoneal approach, the improvements in postoperative recovery may outweigh cosmetic benefits. Park et al. reported that as surgical risk increased, patients prioritized the ideal surgical approach that minimized the risk of complications over cosmetic outcomes.⁷

The role of age and its effect on cosmesis is unclear. Huang et al. reported that age greater or less than 60 years did not affect cosmesis, but this study utilized crowdsourced responses and not patients who underwent surgery, and was in the context of oncologic surgery.⁵ In contrast, Park et al. suggested that younger patients undergoing surgery for benign disease prioritize cosmetic outcomes, but did not include a comparison by age.⁷ Our results provide a definitive answer that patients undergoing reconstructive urologic surgery value cosmesis differently depending on age, with significantly lower median age for both Bother and Consciousness. Of note, 45% of patients younger than 40 years were conscious, and over a third of patients younger than 40 were bothered. Logistic regression demonstrated that for both cosmesis as measured by Bother, and overall Consciousness, older patients were less likely to have a negative perception of their scar. However, it is unclear if this finding is generalizable to patients undergoing oncologic surgery. Further studies should investigate whether age also influences cosmesis outcomes in patients undergoing surgery for malignancy.

Our study confirms that a history of prior abdominal operations did not influence cosmetic outcomes for new scars. The presence of existing abdominal incisions and satisfaction with these incisions has previously been reported to not influence cosmetic satisfaction for new scars.⁵ This study confirms that prior incisions are not associated with cosmetic satisfaction of additional surgical scars, suggesting that patients who already have surgical scars do not care less about cosmesis.

In addition, we found that the use of an assistant port was not associated with Bother or Consciousness, suggesting that an additional small incision did not influence overall cosmesis outcomes, in contrast to the findings of Huang et al.⁵ However, this may be caused by a limited sample size of only six patients with assistant port, with almost all of these periumbilical incisions which were noted to have the lowest Bother and Consciousness of all incisions. Given the limited sample size with the assistant port, we cannot conclude its impact on cosmesis.

Gender was not significantly associated with cosmetic outcomes, a finding that has also been reported for patients undergoing laparoscopic or open donor nephrectomy.²¹ These findings suggest that the scar consciousness of SP and MP incisions does not differ between male and female patients.

This study has several limitations. While this is the first and largest report to compare cosmesis by SP incision site for patients undergoing benign urologic surgery, our results were limited to a single institution study with a relatively small sample size for each incision site. Future studies should expand upon this study by assessing differences between incision sites with larger cohorts. In addition, this study did not assess whether patient satisfaction with scar appearance would change accounting for changes in the benefits of the surgical approach. Periumbilical incisions may provide superior cosmesis, but the benefits of an alternate incision site that lowers the risk of postoperative complications have been suggested to be a greater priority to patients.⁷ A limited sample size of patients with assistant port limits results assessing its impact on cosmesis. The response rate for the questionnaire was also <50%, which may have reflected a selection bias for patients who were most bothered and conscious of their incisions. Lastly, the focus of this study was patients undergoing reconstructive surgery for benign disease. These patients may be more sensitive to cosmetic results as their surgery was performed for benign disease. It has been proposed that patients undergoing surgery for oncologic disease may care less about cosmesis.⁷ Future studies should investigate cosmesis for patients undergoing oncologic surgery.

Conclusions

SP periumbilical incisions provide the best outcomes for cosmesis compared with other SP incision sites and MP incisions. This finding should be discussed and taken into account when planning surgical approaches for patients undergoing benign urologic surgery, especially in patients younger than 40 years of age.

Footnotes

Authors’ Contributions

M.R.: Conceived the project and contributed to the design and implementation of research, data collection, analysis of the results, and writing the article. C.I.: Contributed to the design and implementation of research, data collection, analysis of the results, and writing the article. M.H.: Contributed to data collection and analysis. Q.C.: Contributed to data collection and analysis. K.K.: Contributed to data collection and analysis. S.G.: Contributed to data collection and analysis. S. Saxena: Contributed to data collection and analysis. R.S.D.L.R.: Contributed to data collection and analysis. S. Seidman: Contributed to data collection and analysis. G.L.: Contributed to data collection and analysis. R.M.: Contributed to data collection and analysis and editing the article. M.B.: Contributed to data collection and analysis. M.A.: Contributed to data collection and analysis. M.S.: Conceived the project, contributed to the design and implementation of research, data collection, analysis of the results, and writing the article, and supervised the project.

Author Disclosure Statement

M.R., C.I., M.H., Q.C., K.K., S.G., R.S.D.L.R., S. Seidman, G.L., R.M., and M.B.—None. M.A.—Intuitive Surgery, BioTissue, and Ethicon consultant. M.S.—Intuitive Surgery Advisory Board, VTI consultant, and Ethicon lecturer.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Table S1

Supplementary Table S2

Abbreviations Used

References

Nguyen

, Basilius

, Ali

, Dobbs

, Lee

. Single-port robotic applications in urology. J Endourol, 2023; 37(6):688–699; doi: 10.1089/end.2022.0600

Kaouk

, Garisto

, Bertolo

. Robotic urologic surgical interventions performed with the single port dedicated platform: First clinical investigation. Eur Urol, 2019; 75(4):684–691; doi: 10.1016/j.eururo.2018.11.044

Beksac

, Wilson

, Lenfant

, et al. Single-port mini-Pfannenstiel robotic pyeloplasty: Establishing a non-narcotic pathway along with a same-day discharge protocol. Urology, 2022; 160:130–135; doi: 10.1016/j.urology.2021.10.013

Harrison

, Ahmed

, Billah

, et al. Single-port versus multiport partial nephrectomy: A propensity-score-matched comparison of perioperative and short-term outcomes. J Robot Surg, 2023; 17(1):223–231; doi: 10.1007/s11701-022-01415-8

Huang

, Schwen

, Biles

, et al. A comparative analysis of surgical scar cosmesis based on operative approach for radical prostatectomy. J Endourol, 2021; 35(2):138–143; doi: 10.1089/end.2020.0649

Morgantini

, Del Pino

, Bharadwaj

, et al. Single-port versus multi-port robotic-assisted procedures from the patient’s perspective: A retrospective cohort study. Urol Pract, 2022; 9(6):575–579; doi: 10.1097/UPJ.0000000000000340

Park

, Olweny

, Best

, Tracy

, Mir

, Cadeddu

. Patient-reported body image and cosmesis outcomes following kidney surgery: Comparison of laparoendoscopic single-site, laparoscopic, and open surgery. Eur Urol, 2011; 60(5):1097–1104; doi: 10.1016/j.eururo.2011.08.007

Lenfant

, Wilson

, Sawczyn

, Aminsharifi

, Kim

, Kaouk

. Single-port robot-assisted dismembered pyeloplasty with mini-Pfannenstiel or peri-umbilical access: Initial experience in a single center. Urology, 2020; 143:147–152; doi: 10.1016/j.urology.2020.05.041

Garcia-Roig

, Travers

, McCracken

, Cerwinka

, Kirsch

. Surgical scar location preference for pediatric kidney and pelvic surgery: A crowdsourced survey. J Urol, 2017; 197(3 Pt 2):911–919; doi: 10.1016/j.juro.2016.11.033

10.

Arora

, Swords

, Garas

, et al. The perception of scar cosmesis following thyroid and parathyroid surgery: A prospective cohort study. Int J Surg, 2016; 25:38–43; doi: 10.1016/j.ijsu.2015.11.021

11.

Kaouk

, Garisto

, Eltemamy

, Bertolo

. Robot-assisted surgery for benign distal ureteral strictures: Step-by-step technique using the SP(®) surgical system. BJU Int, 2019; 123(4):733–739; doi: 10.1111/bju.14635

12.

Kaouk

, Garisto

, Eltemamy

, Bertolo

. Single-port robotic intracorporeal ileal conduit urinary diversion during radical cystectomy using the SP surgical system: Step-by-step technique. Urology, 2019; 130:196–200; doi: 10.1016/j.urology.2019.03.023

13.

Abou Zeinab

, Kaviani

, Ferguson

, Beksac

, Eltemamy

, Kaouk

. A transition toward a faster recovery in single-port transvesical simple prostatectomy. J Endourol, 2022; 36(8):1036–1042; doi: 10.1089/end.2021.0805

14.

Checcucci

, De Cillis

, Pecoraro

, et al. Uro-technology and SoMe Working Group of the Young Academic Urologists Working Party of the European Association of urology. Single-port robot-assisted radical prostatectomy: A systematic review and pooled analysis of the preliminary experiences. BJU Int, 2020; 126(1):55–64; doi: 10.1111/bju.15069

15.

Wagenaar

, Nederhoed

, Hoksbergen

AWJ

, Bonjer

, Wisselink

, van Ramshorst

. Minimally invasive, laparoscopic, and robotic-assisted techniques versus open techniques for kidney transplant recipients: A systematic review. Eur Urol, 2017; 72(2):205–217; doi: 10.1016/j.eururo.2017.02.020

16.

Billah

, Sheckley

, Nguyen

, et al. Single port modified partial nephrectomy: Novel simultaneous access to peritoneal and retroperitoneal partial nephrectomy, initial clinical experience. J Endourol, 2024; 38(5):444–449; doi: 10.1089/end.2023.0502

17.

Ramos

, Ferguson

, Abou Zeinab

, et al. Single-port transvesical robot-assisted simple prostatectomy: Surgical technique and clinical outcomes. Eur Urol, 2024; 85(5):445–456; doi: 10.1016/j.eururo.2023.11.012

18.

Fairchild

, Aksenov

, Tejwani

, et al. Single-port Hidden Incision Endoscopic (HIdES) pediatric nephrectomy via Pfannenstiel incision. J Pediatr Urol, 2023; 19(3):339–341; doi: 10.1016/j.jpurol.2023.01.012

19.

Pellegrino

, Chen

, Morgantini

, Calvo

, Crivellaro

. Simplifying retroperitoneal robotic single-port surgery: Novel supine anterior retroperitoneal access. Eur Urol, 2023; 84(2):223–228; doi: 10.1016/j.eururo.2023.05.006

20.

Marks

, Phillips

, Tacchino

, et al. Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg, 2013; 216(6):1037–1047; discussion 1047; doi: 10.1016/j.jamcollsurg.2013.02.0241038

21.

Lind

, Hop

, Weimar

, Ij

. Body image after laparoscopic or open donor nephrectomy. Surg Endosc, 2004; 18(8):1276–1279; doi: 10.1007/s00464-003-9113-x

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB

0.01 MB