title: Comparative study for evaluating the cosmetic outcome of small-incision access retroperitoneoscopic technique (SMART) with standard retroperitoneoscopy using the Observer Scar Assessment Scale: are small incisions a big deal?
abstract: OBJECTIVE
  To compare the scars and cosmetic results of trocars of 3, 5, and 10 mm in cases by small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp) and standard laparoscopy pyeloplasty (SLp).
  
  
  METHODS
  Between January 2012 and October 2013, 20 pyeloplasties were performed: 12 with SMARTp and 8 with SLp techniques. A 5-mm homemade balloon trocar was used to create the retroperitoneal space. In SMARTp, 3- and 5-mm trocars were used and in SLp, 5- and 10-mm trocars were used. All patients underwent a ureteral (Double-J) stent placement preoperatively. The study included a total of 72 trocar-site scars: 3 mm (24 scars), 5 mm (24 scars), and 10 mm (24 scars). Cosmetic outcome was assessed at the 3rd, 12th, and 24th month of surgeries by the Observer Scar Assessment Scale (OSAS).
  
  
  RESULTS
  Mean age was 34.7±10.5 (19-52) years, and mean follow up was 18.7±9.2 months. Fifteen patients (75%) underwent Y-V plasty, and 5 (25%) underwent Anderson-Hynes pyeloplasty. Mean operative time was 125.4±28.7 minutes. There was only minimal blood loss, no need for conversion to standard laparoscopic or open pyeloplasty, no intraoperative complications, and only two postoperative complications were recorded: retroperitoneal hemorrhage and wound infection and both were treated conservatively. There were significant differences between objective questions of "vascularization" in a 3-mm trocar and "thickness" in a 10-mm trocar. Twenty-four months after surgery, the cosmetic data assessed by OSAS showed statistically significant differenecs in favor of the 3-mm trocar sites versus the 10-mm trocar sites (OSAS: 13.8±3.9 vs 24.6±1.7; p=0.006) with no statistically significant difference between 3- and 5-mm port sites.
  
  
  CONCLUSIONS
  The SMARTp is proved to be an efficacious and tolerable procedure with better cosmetic results and can be used for the treatment of ureteropelvic junction obstruction (UPJO) in suitable patients. We believe that this technique is likely to become an established procedure.
authors.affiliation: Department of Urology, Klinikum Heilbronn , Heilbronn, Germany .
authors.forename: Murad
authors.initials: M
authors.lastname: Al Nasser
authors.forename: Giovannalberto
authors.initials: G
authors.lastname: Pini
authors.forename: Ali Serdar
authors.initials: AS
authors.lastname: Gözen
authors.forename: Osama M
authors.initials: OM
authors.lastname: Elashry
authors.forename: Yigit
authors.initials: Y
authors.lastname: Akin
authors.forename: Jan
authors.initials: J
authors.lastname: Klein
authors.forename: Turky
authors.initials: T
authors.lastname: Almouhissen
authors.forename: Jens
authors.initials: J
authors.lastname: Rassweiler
mesh_terms: D000328:Adult; D002921:Cicatrix / Q000209:etiology / Q000473:pathology*; D005260:Female; D006801:Humans; D007682:Kidney Pelvis / Q000601:surgery*; D020706:Laparoscopes / Q000009:adverse effects*; D010535:Laparoscopy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009389:Neovascularization, Pathologic / Q000209:etiology / Q000473:pathology*; D061646:Operative Time; D010858:Pigmentation; D011446:Prospective Studies; D019651:Plastic Surgery Procedures / Q000295:instrumentation; D012187:Retroperitoneal Space / Q000601:surgery*; D014513:Ureter / Q000601:surgery*; D014517:Ureteral Obstruction / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation*; D055815:Young Adult