Surgical Scar Location Preference for Pediatric Kidney and Pelvic Surgery: A
Crowd-Sourced Survey
PII: S0022-5347(16)31727-X
DOI: 10.1016/j.juro.2016.11.033
Reference: JURO 14181
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.
DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a
service to our subscribers we are providing this early version of the article. The paper will be copy edited
and typeset, and proof will be reviewed before it is published in its final form. Please note that during the
production process errors may be discovered which could affect the content, and all legal disclaimers
that apply to The Journal pertain.
Embargo Policy
All article content is under embargo until uncorrected proof of the article becomes available
online.
We will provide journalists and editors with full-text copies of the articles in question prior to the embargo
date so that stories can be adequately researched and written. The standard embargo time is
12:01 AM ET on that date. Questions regarding embargo should be directed to jumedia@elsevier.com.
ACCEPTED MANUSCRIPT
Surgical Scar Location Preference for Pediatric Kidney and Pelvic Surgery: A
Crowd-Sourced Survey
PT
1. Department of Pediatric Urology, Emory University and Childrens Healthcare of
Atlanta, Atlanta, GA
2. Department of Pediatrics - Biostatistics Core, Emory University, Atlanta, GA.
RI
*Correspondence:
Andrew J. Kirsch, MD
SC
Department of Pediatric Urology
5730 Glen Ridge Dr. Suite 200
Atlanta, GA 30328
Telephone: 1(404) 252-5206
U
Fax number: 1(404) 252-1268
Email address: akirschmd@gmail.com
AN
Submission Type: Original Research
M
Figures: 4
TE
Tables: 2
Supplementary tables: 3
EP
References:28
C
Acknowledgements: none
AC
Funding: Self-funded
Abstract
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
PT
patients make for themselves and their children regarding scar location.
RI
Methods: We surveyed preference for scar location/size based on surgery for
SC
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.
U
AN
Results:
M
954 completed surveys were analyzed. Previous surgical history was reported in
Pfannenstiel was the initial choice for 434(45.5%), laparoscopy port incisions
TE
Respondents were told MIS may result in less pain/LOS , and asked to restate
Conclusion: The smallest incision is not always the patients preferred incision,
PT
particularly in childhood when pain, LOS, and blood loss may be equivocal between
RI
approaches. Discussion of surgical treatment options should include scar length,
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
Introduction
Laparoscopy with or without robot assistance has gained popularity due to shorter
PT
length of hospital stay (LOS), smaller incisions, and less blood loss and
RI
postoperative pain for most procedures, especially in adult patients1-3. MIS
specialization has progressed to the point where trainees may have limited open
SC
surgical experience requiring creation of open-surgery fellowship training4.
U
Surgeons strive to perform procedures though the smallest incisions possible to
AN
improve patient experience and maximize cosmesis. However, this approach may
M
experience, and pain perception. We aimed to evaluate the choices adults make for
D
themselves and their children regarding scar location for common pediatric urologic
TE
prefer potentially larger, concealed incisions over smaller, directly visible incisions.
C EP
Methods
AC
Internal review board review deemed this non-human subjects research. A survey
was created assessing preference for surgical scar location and size based on
were asked which approach they preferred if the surgery was performed on them as
drawing depicting scar location relative to undergarments (Figure 1). For both
PT
kidney and pelvic surgery, after asking initial scar location preference, respondents
RI
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
SC
asking respondents to choose again.
U
Non-identifying demographics were collected. For those reporting a history of prior
AN
surgery, basic surgical history was assessed along with scar bother. Scar bother was
M
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.
D
This bother scale was utilized due to strong correlation with bothersome urinary
TE
bothersome scar symptoms does not exist6. Branching logic was used to tailor
EP
detailed surgical history if they had previous surgery, or incision preference for
AC
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.
ACCEPTED MANUSCRIPT
PT
compensation. At the end of our survey, respondents were asked to submit the
RI
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,
SC
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
U
AMT credential restrictions were applied to respondents.
AN
M
Survey response quality was ensured. In addition to the procedure noted above, the
following confirmed result validity. Respondents were asked if they had undergone
D
surgery twice during the survey; first, if they had ever had surgery, then if they had
TE
child, but not on the initial surgery question and these were removed from analysis.
EP
distribution (age, body type, surgical procedure number, surgical scar length, scar
AC
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.
ACCEPTED MANUSCRIPT
for pelvic and kidney surgeries. Means of continuous variables were compared using
PT
t-tests and frequencies of categorical variables were compared using chi-square
RI
tests. Kappa statistics and percent agreement were calculated to measure the
SC
Respondents original surgical preference was compared with preferences
throughout the survey using chi-square tests. Multivariable logistic regression was
U
used to identify significant factors associated with surgery preference. Models were
AN
constructed with the outcomes being Pfannenstiel vs other and DL vs other for
M
pelvic and kidney surgery respectively. Backwards model selection was used with
demographic variables and other variables with unadjusted p-values <0.1 entered
D
into the initial model. Model selection was stopped when no variables included in
TE
alpha level of 0.05 and all statistical analyses were performed using SAS Version 9.4
EP
(Cary, NC).
C
AC
Results
Demographics
954 completed survey responses were included in our analysis. Detailed respondent
six minutes forty three seconds for an hourly rate of $1.787. History of previous
ACCEPTED MANUSCRIPT
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%).
PT
bother responses for pelvis and kidney surgery. Agreement between incision choice
RI
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
SC
for adult as a child.
U
AN
Incision Choice
Respondents were asked their incision preference if surgery was required as a child.
M
For pelvic surgery, Pfannenstiel was the initial choice for 434(45.5%), laparoscopy
follow-up image of incisions in relation to the underwear line, 718 (75.3%) then
TE
Flank incision was the second most common choice for all demographic groups with
C
the exception of Hispanics and those with medical field experience where
AC
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
ACCEPTED MANUSCRIPT
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
PT
surgery regions, a potentially invisible incision upon healing did not alter initial
RI
choice (p<0.001).
SC
Demographics and Incision Choice
The influence of demographics on initial incision choice was assessed. For pelvic
U
surgery, Pfannenstiel was the preferred incision of females more than males (51.6%,
AN
p<0.001); those with children more than those without (52.1%, p<0.001); those
M
more than other US regions (p=0.003); those reporting a hidden scar preference
D
more than those without this preference (57.5%, p<0.001); and those with a high
TE
(p=0.021). Pelvic laparoscopy incisions were initially preferred by men more than
EP
women (46.4% p<0.001); US region: midwest (49.2%) and west coast (49.0%,
C
p<0.001); those without children more than those with children (45.2%, p<0.001);
AC
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%,
smallest previous surgical scar length increased (p=0.003) (Figure 3). Detailed
analysis for pelvic incision preference demonstrated that female gender, having
children, more slender body habitus, and previous scar bother independently
PT
predicted Pfannenstiel incision choice (Table 2).
RI
For kidney surgery, DL was the most common initial incision choice independent of
SC
gender, US residency, residing US region, race or ethnicity, education, medical field
experience, disability status, number of surgery scars, and child surgery history. As
U
previous surgical scar bother increased, choice for DL decreased and flank
AN
increased, however flank was never more prevalent than DL (Figure 4). Detailed
M
predictor of DL preference (Table 2). Previous work in the medical field, black or
TE
Hispanic race, and having had surgery as a child were independently associated
Discussion
AC
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
abdominal port placement for most pediatric urology procedures. Our survey
demonstrates patient preference for surgical scar location varies, with the majority
PT
RI
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
SC
is not as supportive in pediatric urology. For pediatric laparoscopic pyeloplasty,
U
for children and infants8-10. Two groups reported a shorter hospital stay with MIS,
AN
specifically Liu et al reported a LOS of 3.46 days for open, 2.89 for laparoscopic, and
M
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
D
difference in postoperative pain score and analgesic use were reported when
TE
the above reasons, respondents were first asked their preference based on location
EP
questionnaire).
AC
In the current study, respondents preferred hidden incisions primarily. Our findings
contrast those of Barbosa and colleagues13 which reported a strong preference (63-
aspects. We did not directly survey patients and parents facing surgery to avoid
ACCEPTED MANUSCRIPT
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
PT
scarring response and left the impact of scar healing on incision preference to the
RI
respondent. Additionally, the above study (Barbosa, et al) had respondents choose a
SC
however, only two photographs were shown for each incision, all were of light-
U
mature). Recently, Gargollo described an approach to laparoscopic port placement
AN
with incisions hidden below the underwear line (HIDES) in 12 patients, and the
M
ideal approach combining a hidden incision and the benefits of MIS may be along
these lines17.
D
TE
The high prior surgery rate (66%), particularly in childhood (47.8%) may reflect a
however, this rate corresponds with previous reports. Lee et al reported the average
C
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 in 2010 and 78.1 year life expectancy19, one can expect an average American
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
PT
years old based on demographics, therefore, we can assume 50-60% had a single
RI
operative procedure (inpatient, outpatient, and OR vs non-OR) by the time of survey
completion.
SC
The validity of AMT vs in-person survey data has been extensively studied and is
U
considered valid for academic research. Several studies have confirmed respondent
AN
attentiveness is adequate during AMT-based surveys as long as an item confirming
M
checker. Use of AMT in urology research is limited, with most notable work
D
group reported that AMT provides rapid, reliable, and reproducible results with
expert faculty concordance24. Other authors have used AMT to model beliefs in
EP
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
residents, limiting the international applicability of our results. Also, our survey
ACCEPTED MANUSCRIPT
was specific to incisions used in pediatric urologic surgery, specifically the kidney
surgery incisions. Our survey did not specify age at procedure, however, these
pyeloplasty occurs at a median of 10 months old with 15% occurring in 13-18 year
PT
olds9, 26. For pelvic surgery, the incisions described are feasible independent of age.
RI
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.
SC
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
U
used tool throughout academic research21, 22, 24, 27, 28.
AN
M
Conclusion
In this group of nearly 1000 respondents, Pfannenstiel incision was the scar of
D
choice for pelvic surgery in 75.3% and DL incision for kidney surgery in 59.4% of
TE
responders. For pelvic surgery, female gender, having children, more slender body
incision preference. Discussion of surgical treatment options should not only take
AC
into account potential morbidity but scar length and location in relation to
.
ACCEPTED MANUSCRIPT
PT
choice with row percents shown.
RI
choice with row percents shown.
Figure 1. Drawings depicting pelvic and kidney surgery incisions included with
SC
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.
U
Figure 2. Respondent initial pelvic surgery scar location preference stratified by
AN
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
M
References
PT
2. Ghani, K. R., Sukumar, S., Sammon, J. D. et al.: Practice patterns and outcomes
of open and minimally invasive partial nephrectomy since the introduction of
robotic partial nephrectomy: results from the nationwide inpatient sample. J
RI
Urol, 191: 907, 2014
3. Lorentz, C. A., Leung, A. K., DeRosa, A. B. et al.: Predicting Length of Stay
Following Radical Nephrectomy Using the National Surgical Quality
SC
Improvement Program Database. J Urol, 194: 923, 2015
4. Mattar, S. G., Alseidi, A. A., Jones, D. B. et al.: General surgery residency
inadequately prepares trainees for fellowship: results of a survey of
fellowship program directors. Ann Surg, 258: 440, 2013
U
5. Barry, M. J., Fowler, F. J., Jr., O'Leary, M. P. et al.: The American Urological
Association symptom index for benign prostatic hyperplasia. The
AN
Measurement Committee of the American Urological Association. J Urol, 148:
1549, 1992
6. O'Leary M, P.: Validity of the "bother score" in the evaluation and treatment
M
15. Due, E., Rossen, K., Sorensen, L. T. et al.: Effect of UV irradiation on cutaneous
cicatrices: a randomized, controlled trial with clinical, skin reflectance,
histological, immunohistochemical and biochemical evaluations. Acta Derm
Venereol, 87: 27, 2007
16. Visscher, M. O., Bailey, J. K., Hom, D. B.: Scar treatment variations by skin type.
Facial Plast Surg Clin North Am, 22: 453, 2014
17. Gargollo, P. C.: Hidden incision endoscopic surgery: description of technique,
PT
parental satisfaction and applications. J Urol, 185: 1425, 2011
18. National Center for Health Statistics - Inpatient Surgery: Centers For Disease
Control and Prevention, 2010
RI
19. QuickFacts - United States Census: United States Census Bureau
20. Weiser, T. G., Haynes, A. B., Molina, G. et al.: Size and distribution of the global
volume of surgery in 2012. Bull World Health Organ, 94: 201, 2016
SC
21. Bartneck, C., Duenser, A., Moltchanova, E. et al.: Comparing the similarity of
responses received from studies in amazons mechanical turk to studies
conducted online and with direct recruitment. PloS one, 10: e0121595, 2015
22. Rouse, S. V.: A reliability analysis of Mechanical Turk data. Computers in
U
Human Behavior, 43: 304, 2015
23. Hauser, D. J., Schwarz, N.: Attentive Turkers: MTurk participants perform
AN
better on online attention checks than do subject pool participants. Behavior
research methods, 48: 400, 2016
24. Kowalewski, T. M., Comstock, B., Sweet, R. et al.: Crowd-Sourced Assessment
M
treatment choices: The role of numeracy, time discounting, and risk attitudes.
Journal of health psychology: 1359105315615931, 2015
TE
help theorists run behavioral experiments. J Theor Biol, 299: 172, 2012
AC
ACCEPTED MANUSCRIPT
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%)
PT
45 54 126 (13.2%)
55 or older 96 (10.1%)
US Resident
Yes 774 (81.1%)
RI
No 180 (18.9%)
US Region (N = 774)
Midwest 181 (23.4%)
SC
Northeast 149 (19.3%)
Southeast 205 (26.5%)
Southwest 89 (11.5%)
West 143 (18.5%)
Refused 7 (0.9%)
U
Race
White 640 (67.1%)
AN
Black 59 (6.2%)
Asian 213 (22.3%)
Other 33 (3.5%)
Refused 9 (0.9%)
M
Ethnicity
Hispanic 72 (7.6%)
Non-Hispanic 814 (85.3%)
Refused 68 (7.1%)
D
Education
Some HS, HS Graduate 84 (8.8%)
TE
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
PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
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
80% 23
PT
28
70% 41
79
RI
60% 101
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
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
Demographics:
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
U
a. Midwest
AN
b. Northeast
c. Southeast
d. Southwest
e. West
M
a. Male
b. Female
TE
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
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
f. A student
g. Retired
TE
h. Unable to work
i. Prefer not to answer
d. Widowed
e. Divorced
AC
-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. No
c. Prefer not to answer
EP
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-
a. Yes
b. No
AC
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
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
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
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-
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
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-
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
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-
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
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
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
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
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
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
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
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
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
41. If you were told there was a good chance any of the healed scars would be hardly noticeable,
EP
(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
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
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
(N = 647)
Yes 196 (57.5%) 124 (36.4%) 21 (6.2%)
<0.001
TE
(n = 654)
< 1 inch 51 (41.5%) 62 (50.4%) 10 (8.1%)
AC
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
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
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
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
underwear/swimwear?
(N = 647)
TE
PT
RI
U SC
AN
M
D
TE
C EP
AC