Patient-Reported Body Image and Cosmesis Outcomes Following Kidney Surgery: Comparison of Laparoendoscopic Single-Site, Laparoscopic, and Open Surgery

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1 EUROPEAN UROLOGY 60 (2011) available at journal homepage: Kidney Cancer Patient-Reported Body Image and Cosmesis Outcomes Following Kidney Surgery: Comparison of Laparoendoscopic Single-Site, Laparoscopic, and Open Surgery Samuel K. Park a, Ephrem O. Olweny a, Sara L. Best a, Chad R. Tracy b, Saad A. Mir a, Jeffrey A. Cadeddu a, * a Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; b Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Article info Article history: Accepted August 3, 2011 Published online ahead of print on August 12, 2011 Keywords: Laparoendoscopic single-site surgery (LESS) Cosmesis Body image Abstract Background: Laparoendoscopic single-site surgery (LESS) is reported to result in superior cosmesis versus alternative surgical approaches, based solely on surgeon assessment or anecdotal evidence. Objective: Evaluate patient-reported body image and cosmesis outcomes following kidney surgery. Design, setting, and participants: We conducted a prospective and retrospective observational cohort study involving patients who underwent kidney surgery (n = 114) via LESS (n = 35), laparoscopic (n = 52), or open (n = 27) approaches. Cosmesis was evaluated using a comprehensive survey administered 3 mo postoperatively. Measurements: Survey components were a body image questionnaire (BIQ) consisting of body image and cosmesis subscales, a photo-series questionnaire (PSQ) assessing scar preferences after knowledge of scar outcomes for alternative surgical approaches, and query of preference for future surgical approach using a trade-off method. Body image, cosmesis, and PSQ scales ranged from 5 to 20, 3 to 24, and 1 to 10, respectively. Results and limitations: Median BIQ component scores did not significantly differ across surgical approaches. Median ratings for the LESS, laparoscopy, and open scar photographs were 8, 5, and 5, respectively ( p = ). Before viewing photographs, median self-scar ratings for LESS, laparoscopy, and open approaches were 9, 5, and 6.5, respectively ( p = 0.02); after photographs, ratings were 9, 7, and 7, respectively ( p = 0.008). Assuming equivalent surgical risk among the approaches, overall preference for future LESS, laparoscopy, or open surgery was 39%, 33%, or 4%, respectively. As theoretical risk of LESS was raised, preference for LESS decreased, whereas preference for laparoscopy and open surgery increased. Study limitations are a nonrandomized design and the use of a nonvalidated scale. Conclusions: Urologic patients favor LESS cosmesis outcomes over those for laparoscopy or open surgery. Considering the superior scar satisfaction among LESS patients, who were younger and more likely to be undergoing surgery for benign disease, we infer that this demographic most values the cosmetic advantages of LESS. # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, J8.106, Dallas, TX , USA. Tel ; Fax: address: Jeffrey.cadeddu@utsouthwestern.edu (J.A. Cadeddu) /$ see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 1098 EUROPEAN UROLOGY 60 (2011) Introduction Since the initial report of urologic laparoendoscopic singlesite surgery (LESS) in 2007 [1], it has been performed in >1000 cases worldwide [2]. With the exception of cosmesis, clear advantages of LESS over conventional laparoscopy have not been demonstrated to date [3 5]. However, evaluation of LESS cosmesis has largely entailed subjective surgeon assessment [3,4,6 8], with objective evaluation limited by small sample sizes and evaluation as a secondary outcome [9,10]. A validated survey for patient reporting of scarring outcomes after abdominal surgery does not currently exist [11,12]. Alternatively, a comprehensive survey developed by Dunker et al [13] has been widely used for this purpose in several surgical populations [10,13 16]. Dunker s original survey evaluated body image, cosmetic consequences of scarring, and patients preferences for future surgical approach among patients who underwent open or laparoscopic ileocolic resection. Using photographs, the authors examined how patients knowledge of the cosmetic results of alternative surgical approaches affected their own scar assessment. Using similar methodology, we comprehensively evaluated cosmesis outcomes in urologic patients undergoing [(Fig._1)TD$FIG] kidney surgery, comparing LESS with laparoscopic and open surgical approaches. 2. Materials and methods 2.1. Patients After obtaining institutional review board approval, patients scheduled for nephrectomy, nephroureterectomy, partial nephrectomy, or pyeloplasty were recruited. A single surgeon performed all the preoperative evaluation, counseling, and surgery. Choice of a particular surgical approach was based on the surgeon s clinical judgment, taking into consideration patient and clinical factors. Partial nephrectomy and nephroureterectomy were not performed by LESS. As of August 2009, consecutive patients were recruited prospectively. Additionally, consecutive patients who underwent surgery since LESS was first performed at our institution in August 2007 were retrospectively recruited by mail. Surveys were provided 3 mo from the surgery date Surgical techniques Our surgical techniques for conventional laparoscopic and LESS nephrectomyand pyeloplastyhavepreviously beendescribed [1,17,18].Relevantto scarring, an additional 3-mm subxiphoid instrument for liver retraction was used for all right-sided LESS procedures (21 of 35; 60%). For LESS pyeloplasty, an additional 3- or 5-mm lateral instrument was used during the anastomosis in 14 of 17 procedures (82%). 1. Are you less satisfied with your body since the operation? 2. Do you think the operation has damaged your body? 3. Do you feel less attractive as a result of your disease or treatment? 4. Do you feel less feminine/masculine as a result of your disease or treatment? 5. Is it difficult to look at yourself naked? 6. On a scale from 1 to 7, how satisfied are you with your incisional scar? 1 (very (not 5 6 unsatisfied) unsatisfied/not satisfied) 7. On a scale from 1 to 7, how would you describe your incisional scar? 1 (revolting) (not 5 6 revolting/not beautiful) 7 (very satisfied) 7 (beautiful) 8. Could you score your own incisional scar on a scale from 1 to 10 using the scale below? (circle) 1 (Revolting) (not revolting/ (Beautiful) not beautiful) Fig. 1 Body image questionnaire.

3 [(Fig._2)TD$FIG] EUROPEAN UROLOGY 60 (2011) Fig. 2 Photo-series questionnaire.

4 1100 [(Fig._3)TD$FIG] EUROPEAN UROLOGY 60 (2011) If you needed the same surgery again, which technique would you prefer? (circle one) Laparoscopic surgery Single Lap/Umbilical Incision Open It doesn t matter 2. If you were told that single lap/umbilical incision surgery has a 5% greater risk of complications compared to laparoscopic surgery or open surgery and that these complications may require a second surgery, which type of surgery would you choose? (circle one) Laparoscopic surgery Single Lap/Umbilical Incision Open It doesn t matter 3. Which surgery would you choose if the above risk was 10% rather than 5%? (circle one) Laparoscopic surgery Single Lap/Umbilical Incision Open It doesn t matter Fig. 3 Future surgical approach preference questionnaire Postoperative survey 2.4. Statistical analysis The survey used in our study had three main components. In addition to demographic questions, it incorporates a body image questionnaire (BIQ; Fig. 1), a photo-series questionnaire (PSQ; Fig. 2), and a series of questions querying future surgical approach preference in a trade-off manner (Fig. 3). The BIQ (Fig. 1) is an eight-item questionnaire incorporating body image and cosmetic subscales, each with a high internal consistency (Cronbach a of 0.80 and 0.83, respectively) [13]. The body image scale measures patients perception and satisfaction with their bodies after surgery, and it is calculated by reverse scoring and summing the responses to questions 1 through 5; it ranges from 5 to 20 with a higher number representing greater body image perception. The cosmetic scale assesses satisfaction with surgical scars and is calculated by simply summing responses to questions 6 8, for a score range of 3 24, with a higher score indicating greater cosmetic satisfaction [13]. The PSQ asked a total of three questions. First, patients were asked to score their own scars (question 8 of the BIQ) on a Likert scale ranging from 1 (revolting) to 10 (beautiful). They were then asked to rate photographs of scars after LESS, laparoscopic, and open kidney surgery using the same Likert scale. Finally, patients were asked to rescore their own scars after viewing the photographs of alternative scars (Fig. 2). Responses for the entire cohort were used to compare the median ratings of the scar photographs for each approach. Self-scar ratings before and after viewing the photographs were compared for each surgical approach. Lastly, a series of questions queried patients preferences for a future surgical approach, assuming equivalent risk across the different approaches, versus a theoretical increase in the risk of complications with LESS by 5% or 10% (Fig. 3). Survey data were analyzed according to surgical approach using the Kruskal-Wallis test, with post hoc analyses conducted using the Mann- Whitney U test. Surgical approach preference was analyzed using the Fisher exact test. Analyses were performed using GraphPad Prism (Graphpad Software Inc, La Jolla, CA, USA) and Stata v.10 statistical software (StataCorp, College Station, TX, USA). Each analysis performed was two tailed, with a p value 0.05 considered statistically significant. 3. Results 3.1. Demographics A total of 195 surveys were distributed (78 prospective and 117 retrospective). Seven patients were discontinued from the study: Five declined to participate, and two patients did not read English. Of the remaining 188 patients, 114 (61%) returned completed surveys: 67 of 76 (88%) in the prospective group and 47 of 112 (42%) in the retrospective group. Table 1 shows the characteristics of study participants. The patients in the LESS group tended to be younger, thinner, and more likely to be undergoing surgery for nonmalignant indications. There were no conversions from LESS to laparoscopy or from laparoscopy to open surgery in this cohort Body image questionnaire Median composite scores for body image and cosmesis were similar across the groups (Table 2). On pairwise analysis, Table 1 Demographic data LESS (n = 35) Laparoscopic (n = 52) Open (n = 27) Overall (n = 114) Male, n (%) 14 (40) 25 (48) 17 (63) 56 (49) Age, yr, median (range) 44 (18 72) 61 (23 85) 60 (32 77) 56 (18 85) Malignant surgical indication, n (%) 10 (29) 43 (83) 27 (100) 81 (71) Tumor size, cm, mean (range) 4.5 (3 6.5) 4.0 (1.2 10) 3.5 (1.1 9) 3.9 (1.1 10) Previous abdominal surgery, n (%) 15 (43) 32 (62) 17 (63) 65 (57) Body mass index, mean (range) 23.9 ( ) 30.3 ( ) 30.5 ( ) 28.4 ( ) Ethnicity, n (%) White 27 (77) 41(79) 18 (67) 87 (76) Black 2 (6) 4 (8) 3 (11) 9 (8) Hispanic 1 (3) 3 (6) 2 (7) Other 5 (14) 4 (8) 4 (15) 13 (11) Follow-up time, n (%) 3 6 mo 10 (29) 19 (37) 6 (22) 35 (31) 7 12 mo 9 (26) 19 (37) 9 (33) 37 (32) mo 1 (3) 3 (6) 2 (7) 6 (5)

5 EUROPEAN UROLOGY 60 (2011) Table 2 Results of the body image questionnaire according to surgical approach * LESS (n = 35) Laparoscopic (n = 52) Open (n = 27) p value y Body image score, median (IQR) 20 (19 20) 19.5 (17 20) 20 (18 20) 0.06 Cosmetic score, median (IQR) 19 (16 24) 16 ( ) 17 (13 21) 0.06 LESS = laparoscopic single-site surgery; IQR = interquartile range. * Medians and IQRs are shown. y Kruskal-Wallis test. Table 3 Median body image, cosmesis, and self-scar ratings before and after viewing photographs of alternative scars, analyzed according to kidney removal versus nonremoval Pyeloplasty (kidney nonremoval) Nephrectomy (kidney removal) p value * Body image score, median Cosmesis score, median Self-scar rating before photographs, median Self-scar rating after photographs, median * Mann-Whitney U test Photo-series questionnaire Median rating by the entire cohort for the LESS scar photograph was significantly higher than for the laparoscopy ( p < ) or open scar photographs ( p < ) (Fig. 4). Median self-scar ratings both before and after viewing photographs of alternative scars were also significantly higher for the LESS group (before: p = 0.01 for LESS vs laparoscopy and p = 0.01 for LESS vs open; after: p = 0.03 for [(Fig._5)TD$FIG] median body image score was significantly higher for LESS versus laparoscopy ( p = 0.02) but not for LESS versus open ( p = 0.36) or laparoscopy versus open ( p = 0.18). Median cosmesis score was significantly higher for LESS versus open ( p = 0.03) but not LESS versus laparoscopy ( p = 0.055) or laparoscopy versus open ( p = 0.60). To assess the potential impact of scar size on patientreported outcomes within the LESS cohort, body image, cosmesis, and self-scar ratings before and after viewing photographs of alternative scars were analyzed according to kidney removal versus nonremoval (Table 3). Median scores for each of these outcomes did not significantly differ for kidney removal versus nonremoval (Table 3). [(Fig._4)TD$FIG] Fig. 4 Overall median ratings for the scar photographs. 1 Kruskal-Wallis test ( p = ). *Post hoc analysis with Mann-Whitney U test showed significance in pairwise comparison between laparoendoscopic single-site surgery (LESS) versus laparoscopy ( p < ) and LESS versus open groups ( p < ). Fig. 5 Results of self-scar ratings (a) before and (b) after viewing photographs of alternative scars. 1 Kruskal-Wallis test ( p = 0.02). 2 Kruskal-Wallis test ( p = 0.008). *Post hoc analysis with Mann-Whitney U test showed significance in pairwise comparison between laparoendoscopic single-site surgery (LESS) versus laparoscopy and LESS versus open, before ( p = 0.01 and p = 0.01, respectively) and after ( p = 0.03 and p = 0.002, respectively) viewing the photographs.

6 1102 EUROPEAN UROLOGY 60 (2011) Table 4 Preference for future surgical approach, as theoretical risk for laparoendoscopic single-site surgery varies Surgical approach preference LESS approach Laparoscopic approach Open approach No preference Equivalent risk (%) 45/114 (39) 38/114 (33) 5/114 (4) 26/114 (23) 5% greater risk with LESS (%) 34/114 (30) 58/114 (51) 10/114 (9) 12/114 (11) 10% greater risk with LESS (%) 23/114 (20) 63/114 (55) 15/114 (13) 13/114 (11) LESS = laparoendoscopic single-site surgery. LESS vs laparoscopy and p = for LESS vs open) (Fig. 5). Median self-scar ratings for laparoscopy versus open were not significantly different either before or after viewing the photographs ( p = 0.89 and p = 0.42, respectively) Surgical approach preference For the overall cohort, given equivalent risk of complications across the surgical approaches, 45 of 114 patients (39%) would undergo future LESS, in comparison with 38 of 114 (33%) who would elect laparoscopy and 5 of 114 (4%) who would elect open surgery (Table 4). Among those who chose future LESS, 30 of 45 (67%) were from the LESS, 13 of 45 (29%) were from the laparoscopic, and 2 of 45 (4%) were from the open surgery cohorts. Increasing the hypothetical risk of LESS by 5% decreased preference for future LESS to 30% ( p = 0.16), whereas preference for laparoscopy increased to 51% ( p = 0.01) and for open surgery to 9% ( p = 0.29). At 10% increased risk, preference for future LESS, laparoscopy, and open surgery shifted to 20% ( p = 0.002), 55% ( p = 0.001), and 13% ( p = 0.03), respectively. 4. Discussion Previous publications have touted the cosmetic advantages of the LESS approach without objectively studying cosmesis outcomes [3,4,6 8]. A validated survey for patient reporting of scar satisfaction after abdominal surgery presently does not exist [11]. However, several reports in the surgery literature have evaluated cosmesis using the multidimensional survey developed by Dunker et al [13], which quantifies body image perception in addition to cosmesis. Body image is known to have an important influence on patient satisfaction and evaluation of the subjective benefits of surgery [19]. Using Dunker s methodology, we queried body image, cosmesis, and future surgical preference among urologic patients who underwent either extirpative or reconstructive kidney surgery via LESS, laparoscopic, or open approaches. On the BIQ, we found that LESS patients had a significantly higher median body image score than laparoscopic, but not open surgery patients, and a significantly higher median cosmesis score than open surgery patients. However, the absolute differences in these scores between the cohorts were very small, suggesting that a clinically meaningful difference in these outcomes likely does not exist. In contrast, Kurien et al found that body image and cosmesis scores for patients who underwent LESS versus laparoscopic donor nephrectomy were statistically equivalent [10]. On the PSQ, all patients were shown representative photographs of scars after LESS, laparoscopic, or open kidney surgery, so that each patient had knowledge of the cosmetic results of the alternative surgical approaches. The LESS scar photograph was rated as the most cosmetically appealing. Furthermore, on question 8 of the BIQ, where patients were asked to rate their own scars before viewing the photographs, the LESS group rated their scars significantly higher than either of the alternative groups. Ratings after viewing the photographs remained highest for the LESS group. These findings suggest that with more complete knowledge of cosmesis outcomes for the different surgical approaches, LESS scar outcomes are preferred, and that selfscar satisfaction after LESS is higher than that for alternative surgical approaches. Given the fact that LESS patients were more likely to be undergoing surgery for benign indications, the favorable scar satisfaction observed for this group potentially reflects underlying bias due to the fact that surgery for benign disease is expected to yield smaller scars. However, in a subgroup analysis to evaluate this further, median scores for body image, cosmesis, and self-scar ratings before and after viewing photographs of alternative scars did not significantly differ for patients in whom kidney removal versus nonremoval was performed (Table 3), suggesting that in our LESS cohort, scar size did not have an impact on overall scar satisfaction. Lastly, we found that almost 40% of the entire cohort would opt for future LESS if there was no change in the risk of complications. Of those who underwent LESS, 86% would undergo future LESS at equivalent risk, compared with 20% of who would elect future open surgery after having undergone the same. As expected, increasing the theoretical risk of LESS was associated with a decreasing preference for LESS. Interestingly, 20 of 35 of LESS patients (57%) would still choose future LESS at a 10% increased risk. These findings complement those of Bucher et al [20], who reported that 75% of individuals surveyed would choose LESS at equivalent surgical risk to laparoscopy, decreasing to 38% at higher levels of surgical risk. These combined findings demonstrate that surgical safety is the main concern for most patients, but a significant subset of patients appears to prefer LESS even at significantly higher risk. Given that the LESS cohort in our study was overall younger and more likely to be undergoing surgery for benign indications, we postulate that this patient subset most values the cosmetic advantage of LESS, even at

7 EUROPEAN UROLOGY 60 (2011) increased risk. Conversely, the absence of preference for LESS among open surgery patients may be explained by the fact that all patients in the open group underwent surgery for malignant indications, where in many instances open surgery was the only feasible approach; preoperative counseling in these situations may have influenced attitudes toward postoperative cosmetic outcomes. We recognize a few limitations to our study. First, our survey response rate was 61%, and therefore our data are subject to a degree of nonresponse bias. This was despite best efforts to collect responses from all patients, including a follow-up phone call about 1 mo after initial survey distribution if no response was received. Second, patients were not randomized, introducing the potential of bias of presurgical counseling, age, and pathology on perceptions of cosmesis. Furthermore, given the lower mean body mass index for the LESS group, a lower incidence of wound complications among these patients is expected; however, wound-healing complications were not observed in our overall cohort. Additionally, our study may have been underpowered to detect significant differences in a few of the outcomes such as body image. However, we believe that the use of a multidimensional survey enabled us to offset some of the biases just mentioned and to detect some of the underlying differences between the surgical approaches with regard to patients perceptions of cosmetic outcomes. Surveys were not administered at the same time intervals, introducing the potential for differences in reported cosmesis outcomes based on differences in scar appearance. The process of scar maturation is highly variable and may occur over days to years depending on a multitude of factors, but a relatively stable appearance by 3 mo can be expected for most patients. Finally, a nonvalidated survey was used. The standard process of validating a questionnaire is rigorous and to date has not been performed for abdominal surgical scar assessment [11,12]. However, Dunker s questionnaire is a reasonable choice, given its excellent construct validity for body image and cosmesis [13] and its common use. Despite these limitations, we believe that our findings provide valuable insight into the value of LESS cosmetic outcomes to urologic patients. A further prospective study with a larger number of patients will be needed to further evaluate and/or confirm these findings. 5. Conclusions Among scarring outcomes after kidney surgery, patients prefer LESS scar outcomes to those for laparoscopy or open surgery. Considering the prevailing demographic profile of the LESS group (younger, thinner, and more likely to be undergoing surgery for benign indications), we postulate that this patient subset most values the cosmetic benefits of LESS surgery. Author contributions: Jeffrey A. Cadeddu had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tracy, Cadeddu. Acquisition of data: Park, Mir. Analysis and interpretation of data: Park, Olweny, Best. Drafting of the manuscript: Park, Olweny. Critical revision of the manuscript for important intellectual content: Cadeddu, Olweny, Best. Statistical analysis: Park, Olweny. Obtaining funding: None. Administrative, technical, or material support: Tracy, Mir. Supervision: Cadeddu. Other (specify): None. Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None. References [1] Raman JD, Bensalah K, Bagrodia A, Stern JM, Cadeddu JA. Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology 2007;70: [2] Kaouk JH, Autorino R, Kim FJ, et al. Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases. Eur Urol. In press. DOI: /j.eururo [3] Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison of perioperative outcomes and short-term measures of convalescence. Eur Urol 2009;55: [4] Raybourn 3rd JH, Rane A, Sundaram CP. Laparoendoscopic singlesite surgery for nephrectomy as a feasible alternative to traditional laparoscopy. Urology 2010;75: [5] Autorino R, Cadeddu JA, Desai MM, et al. Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2011;59: [6] Tugcu V, Ilbey YO, Mutlu B, Tasci AI. Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study. J Endourol 2010;24: [7] Desai MM, Berger AK, Brandina R, et al. Laparoendoscopic singlesite surgery: initial hundred patients. Urology 2009;74: [8] White WM, Haber GP, Goel RK, Crouzet S, Stein RJ, Kaouk JH. Singleport urological surgery: single-center experience with the first 100 cases. Urology 2009;74: [9] Canes D, Berger A, Aron M, et al. Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison. Eur Urol 2010;57: [10] Kurien A, Rajapurkar S, Sinha L, et al. First prize: standard laparoscopic donor nephrectomy versus laparoendoscopic single-site donor nephrectomy: a randomized comparative study. J Endourol 2011;25: [11] Durani P, McGrouther DA, Ferguson MW. Current scales for assessing human scarring: a review. J Plast Reconstr Aesthet Surg 2009; 62: [12] Durani P, McGrouther DA, Ferguson MW. The Patient Scar Assessment Questionnaire: a reliable and valid patient-reported outcomes measure for linear scars. Plast Reconstr Surg 2009;123: [13] Dunker MS, Stiggelbout AM, van Hogezand RA, Ringers J, Griffioen G, Bemelman WA. Cosmesis and body image after laparoscopicassisted and open ileocolic resection for Crohn s disease. Surg Endosc 1998;12:

8 1104 EUROPEAN UROLOGY 60 (2011) [14] Eshuis EJ, Slors JF, Stokkers PC, et al. Long-term outcomes following laparoscopically assisted versus open ileocolic resection for Crohn s disease. Br J Surg 2010;97: [15] Lind MY, Hop WC, Weimar W, IJzermans JN. Body image after laparoscopic or open donor nephrectomy. Surg Endosc 2004;18: [16] Polle SW, Dunker MS, Slors JF, et al. Body image, cosmesis, quality of life, and functional outcome of hand-assisted laparoscopic versus open restorative proctocolectomy: long-term results of a randomized trial. Surg Endosc 2007;21: [17] Best SL, Donnally C, Mir SA, Tracy CR, Raman JD, Cadeddu JA. Complications during the initial experience with laparoendoscopic single-site pyeloplasty. BJU Int. In press. DOI: /j X x. [18] Tracy CR, Raman JD, Bagrodia A, Cadeddu JA. Perioperative outcomes in patients undergoing conventional laparoscopic versus laparoendoscopic single-site pyeloplasty. Urology 2009;74: [19] Lamade W, Friedrich C, Ulmer C, Basar T, Weiss H, Thon KP. Impact of body image on patients attitude towards conventional, minimal invasive, and natural orifice surgery. Langenbecks Arch Surg 2011;396: [20] Bucher P, Pugin F, Ostermann S, Ris F, Chilcott M, Morel P. Population perception of surgical safety and body image trauma: a plea for scarless surgery? Surg Endosc 2011;25: