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Author's Accepted Manuscript

Surgical Scar Location Preference for Pediatric Kidney and Pelvic Surgery: A
Crowd-Sourced Survey

Michael L. Garcia-Roig , Curtis Travers , Courtney McCracken , Wolfgang


Cerwinka , Jared M. Kirsch , Andrew J. Kirsch

PII: S0022-5347(16)31727-X
DOI: 10.1016/j.juro.2016.11.033
Reference: JURO 14181

To appear in: The Journal of Urology

Please cite this article as: Garcia-Roig ML, Travers C, McCracken C, Cerwinka W, Kirsch JM, Kirsch AJ,
Surgical Scar Location Preference for Pediatric Kidney and Pelvic Surgery: A Crowd-Sourced Survey,
The Journal of Urology (2016), doi: 10.1016/j.juro.2016.11.033.

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Surgical Scar Location Preference for Pediatric Kidney and Pelvic Surgery: A
Crowd-Sourced Survey

Michael L. Garcia-Roig1, Curtis Travers2, Courtney McCracken2, Wolfgang Cerwinka1


Jared M. Kirsch1, Andrew J. Kirsch1*

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1. Department of Pediatric Urology, Emory University and Childrens Healthcare of
Atlanta, Atlanta, GA
2. Department of Pediatrics - Biostatistics Core, Emory University, Atlanta, GA.

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*Correspondence:
Andrew J. Kirsch, MD

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Department of Pediatric Urology
5730 Glen Ridge Dr. Suite 200
Atlanta, GA 30328
Telephone: 1(404) 252-5206

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Fax number: 1(404) 252-1268
Email address: akirschmd@gmail.com
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Submission Type: Original Research
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Text Word Count: 2470

Abstract Word Count: 247


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Figures: 4
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Tables: 2

Supplementary tables: 3
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References:28
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Acknowledgements: none
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Disclosures/Conflicts of interest: none

Funding: Self-funded

Keywords: Scar, laparoscopy, dorsal lumbotomy, pyeloplasty, pediatric urology,

minimally invasive surgery


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Abstract

Purpose: The benefits of minimally invasive surgery (MIS) in pediatric urology,

such as reduced length of hospital stay(LOS) and postoperative pain, are less

predictable when compared to the adult literature. We evaluated the choices adult

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patients make for themselves and their children regarding scar location.

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Methods: We surveyed preference for scar location/size based on surgery for

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bladder and kidney procedures with additional questions assessing the impact of a

hidden incision, LOS, and pain. The survey was posted to Amazon Mechanical Turk.

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Results:
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954 completed surveys were analyzed. Previous surgical history was reported in

660(69%) with scar bother reported by 357(54.2%). For pelvic surgery,


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Pfannenstiel was the initial choice for 434(45.5%), laparoscopy port incisions
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392(41.1%), and 126(13.2%) no preference for incision location. When incisions

were illustrated relative to undergarments, 718 (75.3%)chose Pfannenstiel. For


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kidney surgery, 567(59.4%) initially chose dorsal lumbotomy(DL) incision, flank


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170(17.8%), laparoscopy ports 105(11.0%), and no preference 110(11.5%).


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Respondents were told MIS may result in less pain/LOS , and asked to restate

incision choice; for pelvic surgery, 232/434(53.5%) choosing Pfannenstiel and

282/394(71.6%) choosing laparoscopy remained consistent(p<0.001). For kidney

surgery, 96(56.5%) choosing flank, 322(56.8%) choosing DL, and 68(64.2%)

choosing laparoscopy remained consistent(p=0.349). Agreement between incision


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choice by respondent-as-child and for-child was 82%(=0.69) for pelvic,

84.6%(=0.75) for kidney surgery.

Conclusion: The smallest incision is not always the patients preferred incision,

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particularly in childhood when pain, LOS, and blood loss may be equivocal between

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approaches. Discussion of surgical treatment options should include scar length,

location, and relationship to undergarments.

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Introduction

Surgical options have progressed toward minimally invasive surgery (MIS).

Laparoscopy with or without robot assistance has gained popularity due to shorter

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length of hospital stay (LOS), smaller incisions, and less blood loss and

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postoperative pain for most procedures, especially in adult patients1-3. MIS

specialization has progressed to the point where trainees may have limited open

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surgical experience requiring creation of open-surgery fellowship training4.

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Surgeons strive to perform procedures though the smallest incisions possible to
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improve patient experience and maximize cosmesis. However, this approach may
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not account for patient preferences influenced by self-image, prior surgical

experience, and pain perception. We aimed to evaluate the choices adults make for
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themselves and their children regarding scar location for common pediatric urologic
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procedures of the pelvis and retroperitoneum. We hypothesized that individuals

prefer potentially larger, concealed incisions over smaller, directly visible incisions.
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Methods
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Internal review board review deemed this non-human subjects research. A survey

was created assessing preference for surgical scar location and size based on

procedures for pelvic or kidney surgery (supplementary material). Respondents

were asked which approach they preferred if the surgery was performed on them as

a child. For pelvic surgery, incision options included Pfannenstiel or abdominally-


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located laparoscopy ports. For kidney surgery, options included dorsal

lumbotomy(DL), flank, or laparoscopic ports. For pelvic surgery, a follow-up

question assessed the impact of a hidden incision on preference with an additional

drawing depicting scar location relative to undergarments (Figure 1). For both

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kidney and pelvic surgery, after asking initial scar location preference, respondents

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were asked if an incision with less pain and LOS (laparoscopy) would alter incision

choice. Finally, the impact of a barely noticeable healed incision was assessed by

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asking respondents to choose again.

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Non-identifying demographics were collected. For those reporting a history of prior
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surgery, basic surgical history was assessed along with scar bother. Scar bother was
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adapted from the American Urologic Association Symptom Index global bother

scale: not bothersome at all, bothers me a little, bothers me some, bothers me a lot5.
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This bother scale was utilized due to strong correlation with bothersome urinary
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symptoms in men with benign prostatic hyperplasia as a similar score measuring

bothersome scar symptoms does not exist6. Branching logic was used to tailor
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questions to demographic responses. For example, surveyors were only asked


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detailed surgical history if they had previous surgery, or incision preference for
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their child if they reported having children. The survey was proofread and tested on

ten medical and non-medical personnel, in addition to the authors, prior to data

collection.
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The survey was administered anonymously through Amazon Mechanical

Turk(AMT) (www.mturk.com) via a survey link created within RedCAP (Nashville,

TN). AMT is a crowd-sourcing internet marketplace where individuals can

coordinate the use of humans to complete tasks in exchange for monetary

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compensation. At the end of our survey, respondents were asked to submit the

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survey and copy a code confirming submission into AMT. If the survey was not

expressly submitted upon completion and/or if the code was not copied correctly,

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the survey responses were excluded and the respondent was not paid. Respondents

were paid $0.20 for completing the survey and were assigned a unique identifier. No

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AMT credential restrictions were applied to respondents.
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Survey response quality was ensured. In addition to the procedure noted above, the

following confirmed result validity. Respondents were asked if they had undergone
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surgery twice during the survey; first, if they had ever had surgery, then if they had
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surgery as a child. 46(4.6%) respondents were discordant, indicating surgery as a

child, but not on the initial surgery question and these were removed from analysis.
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Also, demographics were evenly distributed (gender) or represented in a normal


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distribution (age, body type, surgical procedure number, surgical scar length, scar
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bother). Finally, strong agreement was noted in incision preference for the

respondent as a child and for choice for a child offspring for both surgery regions.
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Descriptive statistics were calculated for respondent demographics and surgical

preferences, including means and standard deviations or frequencies and

percentages. Respondent demographics were compared across surgery preference

for pelvic and kidney surgeries. Means of continuous variables were compared using

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t-tests and frequencies of categorical variables were compared using chi-square

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tests. Kappa statistics and percent agreement were calculated to measure the

agreement between respondents preference for themselves and their children.

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Respondents original surgical preference was compared with preferences

throughout the survey using chi-square tests. Multivariable logistic regression was

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used to identify significant factors associated with surgery preference. Models were
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constructed with the outcomes being Pfannenstiel vs other and DL vs other for
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pelvic and kidney surgery respectively. Backwards model selection was used with

demographic variables and other variables with unadjusted p-values <0.1 entered
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into the initial model. Model selection was stopped when no variables included in
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the model were non-significant (p0.05). Statistical significance was assessed at an

alpha level of 0.05 and all statistical analyses were performed using SAS Version 9.4
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(Cary, NC).
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Results

Demographics

954 completed survey responses were included in our analysis. Detailed respondent

demographics are outlined in Table 1. The survey was completed in an average of

six minutes forty three seconds for an hourly rate of $1.787. History of previous
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skin-scarring surgery was reported in 660 (69%), surgery as a child in 457 (47.9%),

and any degree of bother related to surgical scars was reported by 357 (54.2%).

Respondents reported previous surgical scars would be less bothersome if hidden

by underwear in 341/647(52.7%). Figure 2-4 outlines distribution of surgical scar

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bother responses for pelvis and kidney surgery. Agreement between incision choice

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by adult as child and choice for child was 82% (=0.7) for pelvic surgery and 84.6%

(=0.75) for kidney surgery, therefore the results reported represent incision choice

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for adult as a child.

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Incision Choice

Respondents were asked their incision preference if surgery was required as a child.
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For pelvic surgery, Pfannenstiel was the initial choice for 434(45.5%), laparoscopy

incisions for 392(41.1%), and 126(13.2%) had no preference. When shown a


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follow-up image of incisions in relation to the underwear line, 718 (75.3%) then
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chose Pfannenstiel incision. For kidney surgery, DL was chosen by 567(59.4%),

flank 170(17.8%), laparoscopy 105(11.0%), and no preference in 110(11.5%).


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Flank incision was the second most common choice for all demographic groups with
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the exception of Hispanics and those with medical field experience where
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laparoscopy ports were the second most common choice (both p<0.001).

For both operative regions, respondents were then informed that laparoscopy might

result in less pain and shorter LOS. For pelvic surgery, this resulted in an increase in

selection of laparoscopy to 566 (59.3%) and kidney surgery to 400 (41.9%). For
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pelvic surgery, 232 (53.5%) originally choosing Pfannenstiel and 282 (71.6%)

laparoscopy did not change incision choice (p<0.001). For kidney surgery, 96

(56.5%) originally choosing flank, 322 (56.8%) originally choosing DL, and 68

(64.2%) laparoscopy did not change their mind in this scenario(p=0.349). For both

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surgery regions, a potentially invisible incision upon healing did not alter initial

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choice (p<0.001).

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Demographics and Incision Choice

The influence of demographics on initial incision choice was assessed. For pelvic

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surgery, Pfannenstiel was the preferred incision of females more than males (51.6%,
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p<0.001); those with children more than those without (52.1%, p<0.001); those
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living in the northeast (44.3%), southeast (50.7%), or southwest (59.6%) US regions

more than other US regions (p=0.003); those reporting a hidden scar preference
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more than those without this preference (57.5%, p<0.001); and those with a high
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school (45.2%), college (44.3%), or masters or higher (50.0%) education level

(p=0.021). Pelvic laparoscopy incisions were initially preferred by men more than
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women (46.4% p<0.001); US region: midwest (49.2%) and west coast (49.0%,
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p<0.001); those without children more than those with children (45.2%, p<0.001);
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those denying previous surgical scar bother more than those with previous surgical

scar bother (45.9%, p=0.001); and smallest previous surgical scar <1 inch (50%,

p=0.003). As respondent reported previous scar bother increased, preference for

pelvic surgery Pfannenstiel incision increased and laparoscopy ports decreased

(p=0.001) (Figure 2). Moreover, preference for Pfannenstiel incision increased as


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smallest previous surgical scar length increased (p=0.003) (Figure 3). Detailed

pelvic surgery respondent data is reported in Supplementary Table 1. Multivariate

analysis for pelvic incision preference demonstrated that female gender, having

children, more slender body habitus, and previous scar bother independently

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predicted Pfannenstiel incision choice (Table 2).

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For kidney surgery, DL was the most common initial incision choice independent of

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gender, US residency, residing US region, race or ethnicity, education, medical field

experience, disability status, number of surgery scars, and child surgery history. As

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previous surgical scar bother increased, choice for DL decreased and flank
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increased, however flank was never more prevalent than DL (Figure 4). Detailed
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kidney surgery respondent data is reported in Supplementary Table 2. Multivariate

analysis for kidney incision preference identified US residency as an independent


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predictor of DL preference (Table 2). Previous work in the medical field, black or
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Hispanic race, and having had surgery as a child were independently associated

with a non-DL incision.


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Discussion
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Scheussler and colleagues reported the first laparoscopic staging lymphadenectomy

for localized prostate cancer in 19917. MIS has gained popularity across disciplines

due to reduced postoperative pain, LOS, blood loss, and convalescence in addition to

a substantially smaller surgical scar compared to open surgery1-3. MIS requires


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abdominal port placement for most pediatric urology procedures. Our survey

demonstrates patient preference for surgical scar location varies, with the majority

preferring an undergarment-hidden or dorsally-located incision for pelvic and

kidney surgery, respectively.

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There is no doubt in the adult urology literature that MIS results in decreased

postoperative pain, LOS, blood loss, and significantly smaller scars 1-3. The literature

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is not as supportive in pediatric urology. For pediatric laparoscopic pyeloplasty,

three groups independently reported no difference in mean LOS vs open pyeloplasty

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for children and infants8-10. Two groups reported a shorter hospital stay with MIS,
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specifically Liu et al reported a LOS of 3.46 days for open, 2.89 for laparoscopic, and
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1.96 for robot-assisted pyeloplasty (p<0.001) and Penn et al reported a mean 29.3

hour LOS for laparoscopy and only 7 hours longer for open surgery (p=0.06). No
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difference in postoperative pain score and analgesic use were reported when
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comparing pediatric laparoscopic and robot-assisted to open pyeloplasty11, 12. For

the above reasons, respondents were first asked their preference based on location
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alone, then again based on the potential benefits of laparoscopy (supplementary


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questionnaire).
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In the current study, respondents preferred hidden incisions primarily. Our findings

contrast those of Barbosa and colleagues13 which reported a strong preference (63-

93%) for robot-assisted laparoscopic incisions. Our surveys differed in several

aspects. We did not directly survey patients and parents facing surgery to avoid
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referral bias (robotic surgery) or pre-visit research. Moreover, we chose not to show

respondents photographs of healed incisions as this could not account for all mature

scar types, or the impact of sun and skin pigmentation on healing14-16. Our

respondents were over 18 years old; we assumed all were familiar with their bodys

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scarring response and left the impact of scar healing on incision preference to the

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respondent. Additionally, the above study (Barbosa, et al) had respondents choose a

preferred incision based on two photographs of healed incisions and a drawing,

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however, only two photographs were shown for each incision, all were of light-

skinned Caucasian individuals with an ideal scarring outcome14 (flat, light-colored

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mature). Recently, Gargollo described an approach to laparoscopic port placement
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with incisions hidden below the underwear line (HIDES) in 12 patients, and the
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ideal approach combining a hidden incision and the benefits of MIS may be along

these lines17.
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The high prior surgery rate (66%), particularly in childhood (47.8%) may reflect a

willingness to participate in online surveys of this nature causing selection bias;


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however, this rate corresponds with previous reports. Lee et al reported the average
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lifetime number of operating room(OR) and non-OR procedures in the US between


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0-84 years old to be 6 and 3.2, respectively, or a total or 9.2 surgical procedures. [1].

Alternatively, The Centers for Disease Control and Prevention estimated 51.4

million US inpatient procedures occurred in 201018. Based on a population of 309

million in 2010 and 78.1 year life expectancy19, one can expect an average American

to have 13 inpatient procedures in their lifetime. Finally, Weiser et al reported


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global surgery volume based on health expenditure and estimated 11,110 inpatient

surgical procedures per 100,000 people/year for high expenditure countries, such

as the US20. With the above population, this translates to 34.3 mil procedures/year

and 8.7 inpatient procedures/lifetime. Our respondents were most likely 25-44

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years old based on demographics, therefore, we can assume 50-60% had a single

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operative procedure (inpatient, outpatient, and OR vs non-OR) by the time of survey

completion.

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The validity of AMT vs in-person survey data has been extensively studied and is

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considered valid for academic research. Several studies have confirmed respondent
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attentiveness is adequate during AMT-based surveys as long as an item confirming
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attentiveness is present in the survey21-23. Our survey utilized an attentiveness

checker. Use of AMT in urology research is limited, with most notable work
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demonstrated by Lendvay on assessment of surgeon skill in urology. In brief, his


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group reported that AMT provides rapid, reliable, and reproducible results with

expert faculty concordance24. Other authors have used AMT to model beliefs in
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vesicoureteral reflux, and assess prostate cancer decision-making25.


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Our study is not without limitations. This was an online anonymous survey that has

not been validated. Limitations arise in any survey-based data collection, regardless

of the forum - inattention, lack of honesty, indifference, careless answer choices,

differences in question interpretation, etc. The vast majority of respondents were US

residents, limiting the international applicability of our results. Also, our survey
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was specific to incisions used in pediatric urologic surgery, specifically the kidney

surgery incisions. Our survey did not specify age at procedure, however, these

incisions apply to the vast majority requiring kidney procedures as pediatric

pyeloplasty occurs at a median of 10 months old with 15% occurring in 13-18 year

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olds9, 26. For pelvic surgery, the incisions described are feasible independent of age.

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Laparoscopic ports also assume an 8-12 mm outer diameter commonly used in

robotic surgery, which is the most frequently used laparoscopic modality in the US.

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Finally, with AMT, workers select jobs posted to an online forum, causing selection

bias; this is a limitation of any AMT research. Regardless, AMT has become a heavily

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used tool throughout academic research21, 22, 24, 27, 28.
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Conclusion

In this group of nearly 1000 respondents, Pfannenstiel incision was the scar of
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choice for pelvic surgery in 75.3% and DL incision for kidney surgery in 59.4% of
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responders. For pelvic surgery, female gender, having children, more slender body

habitus, and previous surgical scar bother independently predicted Pfannenstiel


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incision preference. For kidney surgery, US residency independently predicted DL


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incision preference. Discussion of surgical treatment options should not only take
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into account potential morbidity but scar length and location in relation to

undergarments whenever possible.

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Table 1. Detailed survey respondent demographics.

Table 2. Multivariate analysis of respondent demographics identifying independent


predictors of incision preference for Dorsal lumbotomy and Pfannenstiel incision for
kidney and pelvic surgery, respectively.

Supplementary Table 1. Tabulated survey responses for pelvic surgery incision

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choice with row percents shown.

Supplementary Table 2. Tabulated survey responses for kidney surgery incision

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choice with row percents shown.

Figure 1. Drawings depicting pelvic and kidney surgery incisions included with

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each question. Incisions are marked in red on abdominal or back drawings. Pelvic
surgery incisions: A. Pfannenstiel, B. 3-port laparoscopy. Pelvic surgery incisions are
shown in relation to underwear. Kidney surgery incisions: A. flank, B. 4-port
laparoscopy, C. dorsal lumbotomy.

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Figure 2. Respondent initial pelvic surgery scar location preference stratified by
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previous surgical scar bother. Preference for Pfannenstiel incision increases as
previous surgical scar bother increases. Column numbers include number of
respondents for each category p=0.001
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Figure 3. Respondent initial pelvic surgery scar location preference stratified by


smallest previous surgical scar length. As smallest previous surgical scar length
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increases, Pfannenstiel preference increases. Column numbers include number of


respondents for each category p=0.003
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Figure 4. Respondent initial Kidney surgery scar location preference stratified by


previous surgical scar bother. As previous surgical scar bother increases, dorsal
lumbotomy preference decreases. Column numbers include number of respondents
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for each category p=0.009


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Characteristic N (%)
Gender
Male 429 (45.0%)
Female 523 (54.8%)
Refused 2 (0.2%)
Age
Less than 25 123 (12.9%)
25 34 400 (41.9%)
35 44 209 (21.9%)

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45 54 126 (13.2%)
55 or older 96 (10.1%)
US Resident
Yes 774 (81.1%)

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No 180 (18.9%)
US Region (N = 774)
Midwest 181 (23.4%)

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Northeast 149 (19.3%)
Southeast 205 (26.5%)
Southwest 89 (11.5%)
West 143 (18.5%)
Refused 7 (0.9%)

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Race
White 640 (67.1%)
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Black 59 (6.2%)
Asian 213 (22.3%)
Other 33 (3.5%)
Refused 9 (0.9%)
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Ethnicity
Hispanic 72 (7.6%)
Non-Hispanic 814 (85.3%)
Refused 68 (7.1%)
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Education
Some HS, HS Graduate 84 (8.8%)
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Some College 189 (19.8%)


Bachelors/ Associate degree 499 (52.3%)
Masters Degree or Higher 182 (19.1%)
Works in Medical Field
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Yes 170 (17.8%)


No 784 (82.2%)
Marital Status
Single (never married) 404 (42.4%)
C

Married 450 (47.2%)


Separated 13 (1.4%)
Widowed 9 (0.9%)
AC

Divorced 65 (6.8%)
Refused 13 (1.4%)
Disabled
Yes 76 (8.0%)
No 862 (90.4%)
Refused 16 (1.7%)
Do you have Children?
Yes 451 (47.2%)
No 496 (52.0%)
Refused 7 (0.7%)
ACCEPTED MANUSCRIPT

Outcome
Pelvic Surgery Kidney Surgery
Variable Pfannenstiel vs Other Dorsal Lumbotomy vs Other

PT
Odds Ratio Odds Ratio
p-value p-value
(95% CI) (95% CI)
US Resident vs Non-US Resident NS NS 2.34 (1.52, 3.91) 0.001

RI
Race/Ethnicity
White NS NS Reference -

SC
Black NS NS 0.53 (0.29, 0.95) 0.034
Hispanic NS NS 0.47 (0.28, 0.81) 0.001
Asian NS NS 0.72 (0.45, 1.16) 0.181

U
Other NS NS 0.90 (0.38, 2.10) 0.800

AN
Works in Medical Field (Yes vs
NS NS 0.44 (0.30, 0.63) <0.001
No)
Female vs Male 1.64 (1.25, 2.15) <0.001 NS NS

M
Disabled (Yes vs No) 1.60 (0.97, 2.64) 0.067 0.63 (0.38, 1.05) 0.075
Have Children (Yes vs No) 1.54 (1.18, 2.03) 0.002 NS NS
Had Surgery as Child NS NS 0.57 (0.43, 0.75) <0.001

D
Body Habitus

TE
1-3 1.81 (1.15, 2.87) 0.011 NS NS
4-6 1.80 (1.24, 2.63) 0.002 NS NS
7-9 Reference - - -
EP
Bothered by Scars
Yes 1.52 (1.12, 2.07) 0.007 NS NS
No/No Surgery Reference - - -
C
AC
ACCEPTED MANUSCRIPT

Pelvic Surgery Incisions Kidney Surgery Incisions

PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT

Pelvic Surgery and Scar Bother


100%
17 7 2
90% 47

PT
80% 12
82 40
70%

RI
60% 138

50%
Don't Care

SC
40% Laparoscopic
30% 26 Pfannenstiel

U
115 56
20% 116
AN
10%
0%
M

Not at all Bothers me a Bothers me Bothers me a


bothersome little some lot
D

Previous Surgical Scar Bother


TE
C EP
AC
ACCEPTED MANUSCRIPT

Pelvic Surgery and Smallest Previous Surgical Scar


100% 3
25 19 7
18
90%

80% 23

PT
28
70% 41
79

RI
60% 101

50% Don't Care

SC
40% Laparoscopic
Pfannenstiel
47

U
30%
64 43
82
AN
20% 76
10%
M

0%
< 1 inch 1 2 3 4 or more
D

Smallest Previous Surgical Scar Length


TE
C EP
AC
ACCEPTED MANUSCRIPT

Kidney Surgery and Previous Surgical Scar Bother


100%
6 2
39 22
90%
18 6
25 30

PT
80%

70% 51
37

RI
27 13
60%
Dont Care

SC
50% Laparoscopic
40% Flank

U
186 Dorsal Lumbotomy
30% 125
52
AN
19
20%

10%
M

0%
Not at all Bothers me Bothers me Bothers me
D

bothersome a little some a lot


TE
C EP
AC
ACCEPTED MANUSCRIPT

Demographics:

1. Do you work in the medical field (physician, nurse, medical assistant,


technician)?
a. Yes
b. No

PT
2. Have you had surgery as a child?
a. Yes
b. No

RI
3. Do you live in the United States?
a. Yes

SC
b. No

Question 4 asked if yes answered to #3:


4. In what region of the United States do you live?

U
a. Midwest
AN
b. Northeast
c. Southeast
d. Southwest
e. West
M

f. Prefer not to answer

5. What is your gender?


D

a. Male
b. Female
TE

c. Prefer not to answer

6. What is your age range?


a. Under 18 years
EP

b. 18 to 24 years
c. 25 to 34 years
d. 35 to 44 years
C

e. 45 to 54 years
f. 55 to 64 years
AC

g. Age 65 or older
h. Prefer not to answer

7. What is your ethnicity?


a. Hispanic
b. Non-hispanic
c. Prefer not to answer

8. What is your race?


a. White
ACCEPTED MANUSCRIPT

b. Black or African American


c. American Indian and Alaska Native
d. Asian
e. Native Hawaiian and Other Pacific Islander
f. Other race
g. Prefer not to answer

PT
9. What is your level of education?
a. Completed some high school
b. High school graduate

RI
c. Completed some college
d. College Associate degree
e. Bachelor's degree

SC
f. Completed some postgraduate
g. Master's degree
h. Ph.D., law or medical degree
i. Other advanced degree beyond a Master's degree

U
j. Prefer not to answer
AN
10. How would you describe your primary occupation
a. Employed for wages
b. Self-employed
M

c. Out of work for more than 1 year


d. Out of work for less than 1 year
e. A homemaker
D

f. A student
g. Retired
TE

h. Unable to work
i. Prefer not to answer

11. What is your marital status?


EP

a. Single (never married)


b. Married
c. Separated
C

d. Widowed
e. Divorced
AC

f. Prefer not to answer

12. Are you disabled?


g. Yes
h. No
i. Prefer not to answer

-New Page-
13. How would you describe your body type on a scale of 1-9?
ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
a. 1-9
M

b. Prefer not to answer


-New Page-
D

14. Have you had any surgery?


a. Yes
TE

b. No
c. Prefer not to answer
EP

Question 15-19 shown if yes to question 14:


15. How many surgical procedures have you had that resulted in a scar?
a. 1 i. 9 q. 17
b. 2 j. 10 r. 18
C

c. 3 k. 11 s. 19
d. 4 l. 12 t. >/=20
AC

e. 5 m. 13 u. prefer
f. 6 n. 14 not to
g. 7 o. 15 answer
h. 8 p. 16

16. About how long or wide (inches) is the smallest surgery scar (excluding
scars from accidents)?
a. 1 c. 3 e. 5
b. 2 d. 4 f. 6
ACCEPTED MANUSCRIPT

g. 7 m. 13 s. 19
h. 8 n. 14 t. >/=20
i. 9 o. 15 u. prefer
j. 10 p. 16 not to
k. 11 q. 17 answer
l. 12 r. 18

PT
17. About how long or wide (inches) is the biggest surgery scar (excluding scars
from accidents)?
a. 1 i. 9 q. 17

RI
b. 2 j. 10 r. 18
c. 3 k. 11 s. 19
d. 4 l. 12 t. >/=20

SC
e. 5 m. 13 u. prefer
f. 6 n. 14 not to
g. 7 o. 15 answer
h. 8 p. 16

U
AN
18. How bothersome would you describe these scars overall?
a. Not at all bothersome
b. Bothers me a little
c. Bothers me some
M

d. Bothers me a lot
e. Prefer not to answer
D

19. Would the scars bother you less if they were hidden under your
underwear/swimwear?
TE

a. Yes
b. No
c. Prefer not to answer
EP

-New Page-

20. Do you have children?


C

a. Yes
b. No
AC

c. Prefer not to answer

Question 21 shown if yes to question 20:


21. Have your kids had surgery as a child?
a. Yes
b. No
c. Prefer not to answer

Question 22-25 shown if yes to question 21:


22. About how long or wide is his or her smallest surgery scar?
ACCEPTED MANUSCRIPT

a. 1 i. 9 q. 17
b. 2 j. 10 r. 18
c. 3 k. 11 s. 19
d. 4 l. 12 t. >/=20
e. 5 m. 13 u. prefer
f. 6 n. 14 not to
g. 7 o. 15 answer

PT
h. 8 p. 16

23. About how long or wide is his or her biggest surgery scar?

RI
a. 1 i. 9 q. 17
b. 2 j. 10 r. 18
c. 3 k. 11 s. 19

SC
d. 4 l. 12 t. >/=20
e. 5 m. 13 u. prefer
f. 6 n. 14 not to
g. 7 o. 15 answer

U
h. 8 p. 16
AN
24. How bothered is your child by their surgery scars?
a. Not at all bothersome
b. Bothers me a little
M

c. Bothers me some
d. Bothers me a lot
e. Prefer not to answer
D
TE

25. Would the scars bother your child less if they were hidden under your childs
underwear/swimwear?
a. Yes
b. No
C EP
AC
ACCEPTED MANUSCRIPT
-New Page-

Pelvic Surgery

Please refer to the image below for the following qustions

PT
RI
U SC
AN
26. If you were born with a problem in the pelvis (like with the bladder) that needed to be fixed with
surgery as a child, which incision (cut) would you rather have? The risks, healing, and the chance
M

of success are the same.


a. A a horizontal (side to side) incision just above the pubic bone (under the belt line),
three inches long
D

b. B three or four incisions on the belly, each about 1/2 inch long
c. I DONT CARE where the scar is located
TE

Question 27 shown if yes to question 20 (have children)


EP

27. If your child was having the same surgery for the first time and you were allowed to choose the
location of their scar, which scar would you choose?
a. A a horizontal (side to side) incision just above the pubic bone (under the belt line),
three inches long
C

b. B three or four incisions on the belly, each about 1/2 inch long
c. I DONT CARE where the scar is located
AC
ACCEPTED MANUSCRIPT
-New Page-

Please refer to the image below for the following questions

PT
RI
U SC
AN
M
D
TE

28. Lets say you chose B in question 1, would you rather have an incision that can be hidden by
EP

underwear/swimwear instead?
a. Yes
b. No
C

Question 28 shown if yes to question 20 (have children)


AC

29. Lets say you chose B for your child in question 2, would you rather your child have an incision
that can be hidden by underwear/swimwear instead?
i. Yes
ii. No
ACCEPTED MANUSCRIPT
-New Page-

Please refer to the image below for the following questions

PT
RI
U SC
AN
M
D
TE

30. Lets say you chose A in question 1, would you change your mind if B meant less pain the day
EP

or two after surgery and going home from the hospital a day earlier but it cant be hidden by
underwear?
a. Yes
b. No
C
AC

Question 31 shown if yes to question 20 (have children)

31. Lets say you chose A for your child in question 2, would you change your mind if B meant less
pain the day or two after surgery and going home from the hospital a day earlier but it cant be
hidden by underwear
a. Yes
b. No
ACCEPTED MANUSCRIPT
-New Page-

Please refer to the image below for the following questions

PT
RI
U SC
AN
M
D
TE
EP

32. If you were told there was a good chance the healed scar would be hardly noticeable, which scar
would you choose?
C

a. A a horizontal (side to side) incision just above the pubic bone (under the belt line),
three inches long
AC

b. B three or four incisions on the belly, each about 1/2 inch long
c. I DONT CARE where the scar is located

Question 33 shown if yes to question 20 (have children)

33. If you were told there was a good chance the healed scar would be hardly noticeable, which scar
would you choose for your child?
a. A a horizontal (side to side) incision just above the pubic bone (under the belt line),
three inches long
b. B three or four incisions on the belly, each about 1/2 inch long
c. I DONT CARE where the scar is located
ACCEPTED MANUSCRIPT
-New Page-

Kidney Surgery

Please refer to the image below for the following questions

PT
RI
U SC
AN
M

34. If you were born with a kidney problem that needed surgery as a child, which incision (cut)
would you rather have? The risk of surgery, healing, and the chance of success are the same.
a. A - on the side, just under the ribs, 1 inch long
D

b. B three or four small incisions on the belly, each about 1/2 inch long
c. C on the back, just under the ribs, 1 inch long
TE

d. I dont care where the scar is located

Question 35 shown if yes to question 20 (have children)


EP

35. If your child was having the same surgery for the first time and you were allowed to choose the
location of their scar, which scar would you choose?
a. A - on the side, just under the ribs, 1 inch long
C

b. B three or four small incisions on the belly, each about 1/2 inch long
c. C on the back, just under the ribs, 1 inch long
AC

d. I dont care where the scar is located on my child


ACCEPTED MANUSCRIPT
-New Page-

Please refer to the image below for the following questions

PT
RI
U SC
AN
36. What if incision B meant less pain the day or two after surgery and going home from the
hospital a day earlier, which one would you choose?
M

a. A - on the side, just under the ribs, 1 inch long


b. B three or four small incisions on the belly, each about 1/2 inch long
c. C on the back, just under the ribs, 1 inch long
D

d. I dont care where the scar is located


TE

Question 37 shown if yes to question 20 (have children)

37. What if incision B meant less pain the day or two after surgery and going home from the
hospital a day earlier, which one would you choose for your child?
EP

a. A - on the side, just under the ribs, 1 inch long


b. B three or four small incisions on the belly, each about 1/2 inch long
c. C on the back, just under the ribs, 1 inch long
C

d. I dont care where the scar is located on my child


AC
ACCEPTED MANUSCRIPT
-New Page-

Please refer to the image below for the following questions

PT
RI
U SC
AN
38. If you were told there was a good chance the healed scar would be hardly noticeable, which scar
would you choose?
M

a. A - on the side, just under the ribs, 1 inch long


b. B three or four small incisions on the belly, each about 1/2 inch long
c. C on the back, just under the ribs, 1 inch long
D

d. I dont care where the scar is located


TE

Question 39 shown if yes to question 20 (have children)

39. If you were told there was a good chance the healed scar would be hardly noticeable, which scar
would you choose for your child?
EP

a. A - on the side, just under the ribs, 1 inch long


b. B three or four small incisions on the belly, each about 1/2 inch long
c. C on the back, just under the ribs, 1 inch long
C

d. I dont care where the scar is located on my child


AC
ACCEPTED MANUSCRIPT
-New Page-

Please refer to the image below for the following questions

PT
RI
U SC
AN
40. If you were told there was a good chance any of the healed scars would be hardly noticeable,
M

which scar would you choose?


a. A - on the side, just under the ribs, 1 inch long
b. B three or four small incisions on the belly, each about 1/2 inch long
D

c. C on the back, just under the ribs, 1 inch long


d. I dont care where the scar is located
TE

Question 41 shown if yes to question 20 (have children)

41. If you were told there was a good chance any of the healed scars would be hardly noticeable,
EP

which scar would you choose for your child?


a. A - on the side, just under the ribs, 1 inch long
b. B three or four small incisions on the belly, each about 1/2 inch long
C

c. C on the back, just under the ribs, 1 inch long


d. I dont care where the scar is located on my child
AC
ACCEPTED MANUSCRIPT

(A) One
(B) 3 or 4
horizontal
incisions on the
incision above the Dont Care
Characteristic belly (1/2 inch p-value
pubic bone (3 (N = 126)
long)
inches long)
(N = 394)
(N = 434)
Gender
Male 164 (38.2%) 199 (46.4%) 66 (15.4%)

PT
<0.001
Female 270 (51.6%) 193 (36.9%) 60 (11.5%)
Age
Less than 25 44 (35.8%) 58 (47.2%) 21 (17.1%)
25 34 193 (48.3%) 156 (39.0%) 51 (12.8%)

RI
35 44 97 (46.4%) 85 (40.7%) 27 (12.9%) 0.525
45 54 55 (43.7%) 54 (42.9%) 17 (13.5%)
55 or older 45 (46.9%) 41 (42.7%) 10 (10.4%)

SC
US Resident
Yes 352 (45.5%) 329 (42.5%) 93 (12.0%)
0.053
No 82 (45.6%) 65 (36.1%) 33 (18.3%)
US Region (N = 767)
Midwest 68 (37.6%) 89 (49.2%) 24 (13.3%)

U
Northeast 66 (44.3%) 56 (37.6%) 27 (18.1%)
Southeast 104 (50.7%) 83 (40.5%) 18 (8.8%) 0.003
AN
Southwest 53 (59.6%) 26 (29.2%) 10 (11.2%)
West 59 (41.3%) 70 (49.0%) 14 (9.8%)
Race
White 280 (43.8%) 278 (43.4%) 82 (12.8%)
M

Black 29 (49.2%) 23 (39.0%) 7 (11.9%)


0.231
Asian 102 (47.9%) 77 (36.2%) 34 (16.0%)
Other 19 (57.6%) 13 (39.4%) 1 (3.0%)
Ethnicity
D

Hispanic 35 (48.6%) 34 (47.2%) 3 (4.2%)


0.093
Non-Hispanic 376 (46.2%) 334 (41.0%) 104 (12.8%)
TE

Education
Some HS, HS Graduate 38 (45.2%) 25 (29.8%) 21 (25.0%)
Some College 84 (44.4%) 81 (42.9%) 24 (12.7%)
Bachelors Degree,
EP

Associate Degree, or 221 (44.3%) 219 (43.9%) 59 (11.8%) 0.021


Some Postgraduate
Masters Degree or
91 (50.0%) 69 (37.9%) 22 (12.1%)
Higher
C

Works in Medical Field


Yes 86 (50.6%) 62 (36.5%) 22 (12.9%)
0.307
No 348 (44.4%) 332 (42.4%) 104 (13.3%)
AC

Marital Status
Single (never married) 166 (41.1%) 181 (44.8%) 57 (14.1%)
Married 221 (39.1%) 173 (38.4%) 56 (12.4%) 0.185
Other 42 (48.3%) 36 (41.4%) 9 (10.3%)
Disabled
Yes 41 (54.0%) 21 (27.6%) 14 (18.4%)
0.041
No 388 (45.0%) 363 (32.1%) 111 (12.9%)
Do you have Children?
Yes 235 (52.1%) 168 (37.3%) 48 (10.6%)
<0.001
No 196 (39.5%) 224 (45.2%) 76 (15.3%)
ACCEPTED MANUSCRIPT

(A) One
(B) 3 or 4
horizontal
incisions on the
incision above the Dont Care
Characteristic belly (1/2 inch p-value
pubic bone (3 (N = 126)
long)
inches long)
(N = 394)
(N = 434)
Previous Childhood
Surgery?

PT
Yes 212 (46.4%) 185 (40.5%) 60 (13.1%)
0.860
No 222 (44.7%) 209 (42.1%) 66 (13.3%)
Any previous surgery?
Yes 313 (47.4%) 272 (41.2%) 75 (11.4%)

RI
0.039
No 111 (40.7%) 116 (42.5%) 46 (16.9%)
Number of Surgery
Scars (N = 655)

SC
1 164 (47.4%) 149 (43.1%) 33 (9.5%)
2 87 (48.3%) 68 (37.8%) 25 (13.9%)
0.744
3 33 (44.0%) 34 (45.3%) 8 (10.7%)
4 or more 27 (50.0%) 21 (38.9%) 6 (11.1%)
How bothersome would

U
you describe these scars?
(N = 658)
AN
Not at all bothersome 116 (38.5%) 138 (45.9%) 47 (15.6%)
Bothers me a little 115 (53.7%) 82 (38.3%) 17 (7.9%)
0.001
Bothers me some 56 (54.4%) 40 (38.8%) 7 (6.8%)
Bothers me a lot 26 (65.0%) 12 (30.0%) 2 (5.0%)
M

Would the scars bother


you less if they were
hidden under your
underwear/swimwear?
D

(N = 647)
Yes 196 (57.5%) 124 (36.4%) 21 (6.2%)
<0.001
TE

No 113 (36.9%) 143 (46.7%) 50 (16.3%)


Smallest Scar Length
(n = 656)
< 1 inch 76 (37.6%) 101 (50.0%) 25 (12.4%)
1 82 (45.6%) 79 (43.9%) 19 (10.6%)
EP

2 64 (52.0%) 41 (33.3%) 18 (14.6%) 0.003


3 47 (64.4%) 23 (31.5%) 3 (4.1%)
4 or more 43 (55.1%) 28 (35.9%) 7 (9.0%)
Largest Scar Length
C

(n = 654)
< 1 inch 51 (41.5%) 62 (50.4%) 10 (8.1%)
AC

1 50 (46.7%) 43 (40.2%) 14 (13.1%)


2 53 (46.5%) 43 (37.7%) 18 (15.8%) 0.285
3 40 (47.1%) 35 (41.2%) 10 (11.8%)
4 or more 117 (52.0%) 88 (39.1%) 20 (8.9%)
ACCEPTED MANUSCRIPT

(A) One on (B) 3 or 4 (C) One on


the side, incisions on the back,
Dont
just under the belly, just under
Characteristic Care p-value
the ribs (1 (1/2 inch the ribs (1
(N = 110)
inch long) long) inch long)
(N = 170) (N = 105) (N = 567)
Gender
Male 72 (16.8%) 59 (13.8%) 242 (56.4%) 56 (13.1%)

PT
0.036
Female 98 (18.7%) 46 (8.8%) 325 (62.1%) 54 (10.3%)
Age
Less than 25 22 (17.9%) 17 (13.8%) 71 (57.7%) 13 (10.6%)
25 34 70 (17.5%) 51 (12.8%) 236 (59.0%) 43 (10.8%)

RI
35 44 30 (14.4%) 23 (11.0%) 131 (62.7%) 25 (12.0%) 0.162
45 54 22 (17.5%) 12 (9.5%) 72 (57.1%) 20 (15.9%)
55 or older 26 (27.1%) 3 (3.1%) 57 (59.4%) 10 (10.4%)

SC
US Resident
Yes 130 (16.8%) 65 (8.4%) 495 (64.0%) 84 (10.9%)
<0.001
No 40 (22.2%) 41 (22.8%) 72 (40.0%) 27 (15.0%)
US Region (N = 767)
Midwest 23 (12.7%) 14 (7.7%) 116 (64.1%) 28 (15.5%)

U
Northeast 26 (17.5%) 10 (6.7%) 97 (65.1%) 16 (10.7%)
Southeast 28 (13.7%) 24 (11.7%) 134 (65.4%) 19 (9.3%) 0.027
AN
Southwest 22 (24.7%) 10 (11.2%) 49 (55.1%) 8 (9.0%)
West 31 (21.7%) 5 (3.5%) 95 (66.4%) 12 (8.4%)
Race
White 99 (15.5%) 44 (6.9%) 426 (66.6%) 71 (11.1%)
M

Black 15 (25.4%) 6 (10.2%) 30 (50.9%) 8 (13.6%)


<0.001
Asian 50 (23.5%) 45 (21.1%) 90 (42.3%) 28 (13.2%)
Other 5 (15.2%) 8 (24.2%) 18 (54.6%) 2 (6.1%)
Ethnicity
D

Hispanic 17 (23.6%) 17 (23.6%) 32 (44.4%) 6 (8.3%)


<0.001
Non-Hispanic 141 (17.3%) 76 (9.3%) 509 (62.5%) 88 (10.8%)
TE

Education
Some HS, HS Graduate 20 (23.8%) 3 (3.6%) 47 (56.0%) 14 (16.7%)
Some College 28 (14.8%) 15 (7.9%) 123 (65.1%) 23 (12.2%)
Bachelors Degree,
EP

Associate Degree, or 85 (17.0%) 53 (10.6%) 304 (60.9%) 57 (11.4%) 0.002


Some Postgraduate
Masters Degree or
37 (20.3%) 35 (19.2%) 93 (51.1%) 17 (9.3%)
Higher
C

Work in Medical Field


Yes 40 (23.5%) 36 (21.2%) 69 (40.6%) 25 (14.7%)
<0.001
No 130 (16.6%) 70 (8.9%) 498 (63.5%) 86 (11.0%)
AC

Marital Status
Single (never married) 73 (18.1%) 42 (10.4%) 246 (60.9%) 43 (10.6%)
Married 77 (17.1%) 58 (12.9%) 259 (57.6%) 56 (12.4%) 0.239
Other 18 (20.7%) 4 (4.6%) 58 (66.7%) 7 (8.1%)
Disabled
Yes 15 (19.7%) 12 (15.8%) 38 (50.0%) 11 (14.5%)
0.300
No 151 (17.5%) 93 (10.8%) 521 (60.4%) 97 (11.3%)
Do you have
Children?
Yes 84 (18.6%) 55 (12.2%) 257 (57.0%) 55 (12.2%)
0.458
No 86 (17.3%) 50 (10.1%) 307 (61.9%) 53 (10.7%)
ACCEPTED MANUSCRIPT

(A) One on (B) 3 or 4 (C) One on


the side, incisions on the back,
Dont
just under the belly, just under
Characteristic Care p-value
the ribs (1 (1/2 inch the ribs (1
(N = 110)
inch long) long) inch long)
(N = 170) (N = 105) (N = 567)
Previous childhood
surgery

PT
Yes 95 (20.8%) 67 (14.7%) 236 (51.6%) 59 (12.9%)
<0.001
No 75 (15.1%) 39 (7.9%) 331 (66.6%) 52 (10.5%)
Any previous surgery
Yes 128 (19.4%) 79 (12.0%) 383 (58.0%) 70 (10.6%)

RI
0.043
No 40 (14.7%) 21 (7.7%) 176 (64.5%) 36 (13.2%)
Number of Surgery
Scars (N = 655)

SC
1 59 (17.1%) 36 (10.4%) 221 (63.9%) 30 (8.7%)
2 37 (20.6%) 29 (16.1%) 89 (49.4%) 25 (13.9%)
0.010
3 22 (29.3%) 4 (5.3%) 43 (57.3%) 6 (8.0%)
4 or more 10 (18.5%) 10 (18.5%) 27 (50.0%) 7 (13.0%)
How bothersome

U
would you describe
these scars? (N = 658)
AN
Not at all bothersome 51 (16.9%) 25 (8.3%) 186 (61.8%) 39 (13.0%)
Bothers me a little 37 (17.3%) 30 (14.0%) 125 (58.4%) 22 (10.3%)
0.009
Bothers me some 27 (26.2%) 18 (17.5%) 52 (50.5%) 6 (5.8%)
Bothers me a lot 13 (32.5%) 6 (15.0%) 19 (47.5%) 2 (5.0%)
M

Would the scars


bother you less if they
were hidden under
your
D

underwear/swimwear?
(N = 647)
TE

Yes 71 (20.8%) 50 (14.7%) 189 (55.4%) 31 (9.1%)


0.066
No 54 (17.7%) 28 (9.2%) 187 (61.1%) 37 (12.1%)
Smallest Scar Length
(n = 656)
< 1 inch 28 (13.9%) 19 (9.4%) 129 (63.9%) 26 (12.9%)
EP

1 40 (22.2%) 28 (15.6%) 94 (52.2%) 18 (10.0%)


2 24 (19.5%) 13 (10.6%) 73 (59.4%) 13 (10.6%) 0.086
3 23 (31.5%) 8 (11.0%) 38 (52.1%) 4 (5.5%)
4 or more 13 (16.7%) 11 (14.1%) 47 (60.3%) 7 (9.0%)
C

Largest Scar Length


(n = 654)
AC

< 1 inch 17 (13.8%) 15 (12.2%) 80 (65.0%) 11 (8.9%)


1 18 (16.8%) 17 (15.9%) 56 (52.3%) 16 (15.0%)
2 23 (20.2%) 11 (9.7%) 67 (58.8%) 13 (11.4%) 0.199
3 18 (21.2%) 6 (7.1%) 50 (58.8%) 11 (12.9%)
4 or more 52 (23.1%) 30 (13.3%) 128 (56.9%) 15 (6.7%)
ACCEPTED MANUSCRIPT

Definitions for abbreviations:

MIS: minimally invasive surgery


LOS: length of stay
DL: dorsal lumbotomy

PT
RI
U SC
AN
M
D
TE
C EP
AC