Patient-reported outcomes after hemorrhoid surgery: early results from a prospective, nationwide, real-world, cohort study on diverse approaches

Metin Kement; Atıf Tekin; Hakan Baysal; Salih Tosun; Orhan Alimoğlu; İlker Sücüllü; Osman Civil; Nevin Sakoğlu; Naciye Çiğdem Arslan; Cihad Tatar; Ali Emre Naycı; Aziz Arı; Ensar Çakır; Rozan Kaya; İlknur Turan; Taygun Gülşen; Serhat Meriç; Erkan Yavuz; Nihat Buğdaycı; Farid Mohamad Hamad; Sezai Leventoğlu; Ramazan Kozan; Özkan Akpınar; Hakan Yanar; Fatih Yanar; Hasan Fehmi Küçük; Mehmet Karahan; Selçuk Kaya; Nail Can Adıgüzel; Tolga Önder; İlker Abcı; Ahmet Zeki Aydın; Ömer Faruk Özkan; Nurhilal Kızıltoprak; Berkay Özcan; Anıl Orhan; Alp Ömer Cantürk; Murat Tan; Yusuf Bilgin; Harun Çok; Azamet Cezit; Mehmet Mahir Fersahoğlu; Mustafa Öncel

doi:10.3393/ac.2025.00710.0101

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Original Article Anorectal benign disease Patient-reported outcomes after hemorrhoid surgery: early results from a prospective, nationwide, real-world, cohort study on diverse approaches: Metin Kement¹, Atıf Tekin², Hakan Baysal³, Salih Tosun³, Orhan Alimoğlu³, İlker Sücüllü⁴, Osman Civil⁵, Nevin Sakoğlu⁵, Naciye Çiğdem Arslan⁵, Cihad Tatar⁶, Ali Emre Naycı⁶, Aziz Arı⁶, Ensar Çakır⁶, Rozan Kaya⁶, İlknur Turan⁷, Taygun Gülşen⁸, Serhat Meriç⁹, Erkan Yavuz⁹, Nihat Buğdaycı⁹, Farid Mohamad Hamad⁹, Sezai Leventoğlu¹⁰, Ramazan Kozan¹⁰, Özkan Akpınar¹⁰, Hakan Yanar¹¹, Fatih Yanar¹², Hasan Fehmi Küçük¹³, Mehmet Karahan¹³, Selçuk Kaya¹³, Nail Can Adıgüzel¹³, Tolga Önder¹⁴, İlker Abcı⁴, Ahmet Zeki Aydın⁴, Ömer Faruk Özkan¹⁵, Nurhilal Kızıltoprak¹⁵, Berkay Özcan¹⁵, Anıl Orhan¹⁶, Alp Ömer Cantürk¹⁷, Murat Tan¹⁸, Yusuf Bilgin¹⁹, Harun Çok¹⁹, Azamet Cezit¹⁹, Mehmet Mahir Fersahoğlu²⁰, Mustafa Öncel²; Annals of Coloproctology 2025;41(6):573-585.
DOI: https://doi.org/10.3393/ac.2025.00710.0101
Published online: December 30, 2025

¹VM Medical Park Hospital, Istanbul, Turkiye

²Medipol Mega University Hospital, Istanbul, Turkiye

³Göztepe Training and Research Hospital, Istanbul, Turkiye

⁴Private Practice, Istanbul, Turkiye

⁵Bahçelievler Medipol University Hospital, Istanbul, Turkiye

⁶Istanbul Training and Research Hospital, Istanbul, Turkiye

^7ÜmraniyeTraining and Research Hospital, Istanbul, Turkiye

⁸Sultanbeyli State Hospital, Istanbul, Turkiye

⁹Bağcılar Training and Research Hospital, Istanbul, Turkiye

¹⁰Gazi University Faculty of Medicine, Ankara, Turkiye

¹¹Liv Hospital Ulus, Istanbul, Turkiye

¹²Istanbul University Faculty of Medicine, Istanbul, Turkiye

¹³Kartal Lütfü Kırdar Training and Research Hospital, Istanbul, Turkiye

¹⁴Taksim Training and Research Hospital, Istanbul, Turkiye

¹⁵Sultan Abdülhamid Han Training and Research Hospital, Istanbul, Turkiye

¹⁶Haseki Training and Research Hospital, Istanbul, Turkiye

¹⁷Sakarya Training and Research Hospital, Sakarya, Turkiye

¹⁸Ataşehir Florence Nightingale Hospital, Istanbul, Turkiye

¹⁹Kanuni Training and Research Hospital, Istanbul, Turkiye

²⁰Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkiye

Correspondence to: Atıf Tekin, MD Medipol Mega University Hospital, TEM Avrupa Otoyolu Göztepe Çıkışı No. 1, Bağcılar, Istanbul 34214, Turkiye Email: atif.tekin@medipol.edu.tr

• Received: June 2, 2025 • Revised: July 30, 2025 • Accepted: August 21, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
Supplementary materials
REFERENCES

Abstract

Purpose
Real-world evidence comparing surgical techniques for symptomatic hemorrhoidal disease (HD) remains limited, despite the availability of multiple approaches. This study aimed to evaluate short-term, interim outcomes from a prospective, nationwide cohort study that compared the effectiveness of different operative techniques based on patient-reported outcome measures (PROMs) in patients with symptomatic HD.
Methods
A prospective, nationwide cohort study was conducted at 20 tertiary care centers across Turkiye between July 2022 and July 2024. Adult patients aged 18 years or older with symptomatic HD (grades I–IV) who underwent surgery during this period were included. The choice of procedure was determined by the operating surgeon, and patients were categorized into excisional, fixative, and ablative groups according to the surgical approach used. The primary outcomes were changes in the Hemorrhoidal Disease Symptom Score, Short Health ScaleHD, visual analog scale for pain, and patient satisfaction, assessed from the preoperative period to postoperative day 7 and postoperative week 6.
Results
The study included a total of 315 patients after excluding those who did not fulfil the inclusion criteria. Among them, 239 (75.9%) were male, with a mean age of 43.7±11.7 years. The distribution of patients across surgical groups was 207 (65.7%) in the excisional group, 30 (9.5%) in the fixative group, and 78 (24.8%) in the ablative group. All groups demonstrated significant improvements in PROM scores from preoperative to postoperative assessments. However, no statistically significant differences were observed between groups at any time point for PROM scores or for changes in PROM scores across consecutive evaluations (P≥0.05 for all comparisons). Urinary retention occurred more frequently, and hospital stays were longer in the fixative group (P=0.006 and P<0.001, respectively). The excisional group had a greater need for narcotic use and longer duration of use (P=0.003 and P<0.001, respectively).
Conclusion
This real-world cohort study shows that all 3 surgical approaches are effective for HD, providing comparable short-term symptomatic relief and patient satisfaction. These techniques appear equally valid treatment options, and the choice of procedure may best be individualized based on patient-specific characteristics and surgeon preference.
Trial registration
ClinicalTrials.gov identifier: NCT05429060
Keywords: Hemorrhoidectomy; Hemorrhoidal disease; Hemorrhoid surgery

INTRODUCTION

Hemorrhoidal disease (HD) is one of the most common anorectal disorders, affecting a large proportion of the adult population worldwide. It is estimated that up to 50% of individuals over 50 years of age experience symptomatic HD at some point in their lives, and approximately 5% of the general population seek medical or surgical treatment for this condition [1, 2]. Despite its high prevalence, HD is often underreported, likely due to the social stigma associated with anorectal complaints and the variability of symptom presentation [3, 4].

HD can substantially impair quality of life, producing physical discomfort, psychological distress, and functional limitations [5]. Typical symptoms include pain, itching, swelling, and bleeding, which may interfere with activities such as sitting, walking, and defecation [6]. These symptoms can contribute to fatigue, sleep disturbances, and restrictions in daily activities, ultimately reducing work productivity and hindering social interactions [5, 6].

Patient-reported outcome measures (PROMs) are essential for evaluating the impact of hemorrhoidal symptoms on daily life. PROMs provide valuable insight into disease burden and enable clinicians to directly capture patients’ perspectives on their condition and treatment responses.

Management strategies for HD range from conservative approaches, such as dietary modifications and topical therapies, to office-based procedures and surgical interventions. Treatment selection depends on disease severity and patient-specific factors. While conservative measures are effective in patients with mild to moderate disease, more advanced stages often require procedural or surgical management, including rubber band ligation, laser ablation, or hemorrhoidectomy. Despite the availability of multiple treatment modalities, recurrence remains a persistent issue, underscoring the need for continued research to optimize therapeutic strategies.

Although many studies have evaluated the outcomes of different surgical techniques, there remains a scarcity of real-world evidence, particularly with respect to differential effects on PROMs. This interim analysis reports the first 6-week outcomes of an ongoing 12-month follow-up study, with final results anticipated in June 2025. These early findings provide timely insight into immediate postoperative outcomes while long-term data collection is ongoing.

This study presents an interim analysis of a prospective, nationwide cohort study comparing the effectiveness of different surgical techniques for symptomatic HD, as assessed by PROMs.

METHODS

Ethics statement

This study was approved by the Istanbul Medipol University Research Committee and the Institutional Ethics Committee (No. E-10840098-772.02-3634). All participants were fully informed about the study protocol and provided written consent prior to enrollment. The trial was registered at ClinicalTrials.gov (identifier: NCT05429060) for transparency and adherence to research standards. The study was conducted in compliance with the Declaration of Helsinki.

Study design

The study was conducted between July 2022 and July 2024 at 20 tertiary centers representing diverse regions of Turkiye. Since long-term data collection is ongoing, with completion expected in June 2025, this report presents an interim analysis focusing on short-term outcomes.

Patient selection and exclusion criteria

Eligible participants were patients aged 18 years or older with symptomatic grade I–IV HD who underwent surgery at the participating centers during the study period. All patients had received at least 4 weeks of conservative treatment prior to surgery and underwent sigmoidoscopy (or colonoscopy for those over 50 years of age). Exclusion criteria included the presence of concomitant proctological conditions (fistula, perianal abscess, or anal fissure), prior surgery for these disorders, previous surgery for HD, inflammatory bowel disease, history of pelvic or perineal radiation, prior obstetric or traumatic injury to the perianal region or related surgery such as sphincter repair, and previous rectal surgery for either benign or malignant disease.

Surgical interventions and group classification

The choice of surgical technique was left to the discretion of the surgeon, and patients were classified into excisional, fixative, or ablative groups based on the procedure performed. The techniques were categorized as follows: (1) excisional: Milligan-Morgan (n=59) or Ferguson hemorrhoidectomy (n=43) with or without using a sealing device (n=105); (2) fixative: stapler hemorrhoidopexy (Longo technique, n=5) or Doppler-guided hemorrhoidal artery ligation (HAL) with or without mucopexy (n=25); and (3) ablative: hemorrhoidal laser procedure (HeLP; n=78).

For patients undergoing combined procedures, classification was determined by the more invasive technique, based on the extent of tissue resection and anticipated recovery time, following established surgical hierarchy principles. Within the excisional group, surgeons selected between Milligan-Morgan (open defect), Ferguson (closed defect), or vessel sealer techniques depending on patient characteristics and surgeon preference. While this introduced some heterogeneity, it accurately reflects real-world clinical practice.

All procedures were performed by staff-level proctologists (89.9% overall) or by residents under direct supervision. Although detailed operative steps were not standardized across centers in order to reflect routine practice, all institutions followed their respective standard protocols (Tabe 1). Local anesthetic dosing was at the surgeon’s discretion, typically involving 10 to 20 mL of 0.5% bupivacaine for perianal infiltration when applied.

Data collection and outcomes

Operating surgeons or surgical teams documented patient demographics, body mass index (BMI), anticoagulant use, American Society of Anesthesiologists (ASA) physical status, comorbidities, and prior obstetric or surgical history. They also recorded presenting symptoms (pain, bleeding, itching, prolapse, soiling, tenesmus, constipation, and incontinence), physical findings (prolapse and skin tags), and disease severity according to the Goligher classification [7, 8]. Surgical details were also noted, including the surgeon's experience level (staff or resident under supervision), operation time, and type of anesthesia (general, regional, or local anesthesia with sedation). Applications of perianal local anesthetics and pudendal block were also recorded. Intraoperative and early postoperative complications, including bleeding, urinary retention and abscess, and reoperations due to complications, were documented.

All data from participating institutions were centralized at the study secretariat. On postoperative day 7 and postoperative week 6, trained nurses contacted patients by telephone to administer the Hemorrhoidal Disease Symptom Score (HDSS), Short Health ScaleHD (SHSHD), Patient Satisfaction Score (PSS), and visual analog scale (VAS) questionnaires. Nurses conducting the interviews were blinded to the surgical technique used and were not involved in patient care. Each call lasted approximately 15 to 20 minutes to minimize fatigue-related bias. Nevertheless, reliance on telephone-based PROMs introduces a potential source of bias that should be considered when interpreting subjective outcomes.

Patient-reported outcome measures

PROMs were assessed using 4 validated questionnaires selected for their established use in hemorrhoidal disease research and their ability to capture comprehensive patient experiences: (1) HDSS, a 5-item scale on complaints (possible range, 0–20); (2) SHSHD, a 4-item scale on HD-related quality of life (possible range, 0–21); (3) VAS, a visual pain scoring system (possible range, 0–10); and (4) PSS, a single-item measure (possible range, 1–7), with lower scores indicating higher satisfaction [9, 10].

VAS was additionally assessed on day 0 using the same procedure. The initial administration of all questionnaires was conducted preoperatively via face-to-face interviews by operative staff. Early postoperative complications, including bleeding, urinary retention, and abscess formation, were evaluated on postoperative day 7. The study protocol also included long-term follow-up for complications such as stenosis, incontinence, and fistula, as well as patient satisfaction at 12 months. However, this interim analysis focuses only on short-term outcomes.

A comparative analysis was conducted to assess differences in baseline patient and disease characteristics across treatment groups. Changes in PROMs over time were analyzed to determine the relative effectiveness of different surgical techniques. Subgroup analyses were also performed according to symptom type and HD grade. Additional subgroup analyses within each surgical technique category were conducted when sample sizes permitted meaningful comparisons.

Statistical analysis

All statistical analyses were performed using IBM SPSS ver. 26 (IBM Corp). Descriptive statistics were used to summarize baseline patient characteristics and outcome measures across the 3 treatment groups. Continuous variables (e.g., age, BMI, VAS, HDSS, and SHSHD) were expressed as mean±standard deviation. Categorical variables (e.g., sex, comorbidities, and postoperative complications) were summarized as frequencies and percentages.

For comparisons of continuous variables among the 3 groups, a one-way analysis of variance (ANOVA) was used for normally distributed data. Normality was assessed using the Shapiro-Wilk test. For non-normally distributed data, the Kruskal-Wallis test was applied. Post hoc pairwise comparisons were conducted using the Tukey honestly significant difference test (for normally distributed variables) or Dunn test (for non-normally distributed variables). Categorical variables were analyzed with the chi-square test or Fisher exact test, as appropriate. For significant chi-square results, adjusted residuals were examined to identify the specific cells contributing to significance. A P-value of <0.05 was considered statistically significant.

Longitudinal PROMs, including VAS, HDSS, and SHSHD, were measured at 3 time points (preoperatively, postoperative day 7, and postoperative week 6). Changes over time within and between groups were assessed using repeated measures ANOVA, evaluating both main effects (time, group) and interaction effects (time×group). For non-normally distributed longitudinal data, the Friedman test was used as an alternative. When significant effects were detected, post hoc pairwise analyses with Bonferroni correction were conducted to adjust for multiple comparisons.

Missing data occurred primarily due to patient nonresponse to telephone follow-up (loss to follow-up rate, 4.6% at 6 weeks). Missing data were addressed using multiple imputation, assuming missing-at-random. Five imputed datasets were generated and analyzed separately, with results pooled using Rubin rules to account for imputation variability. Sensitivity analyses were also performed excluding patients who underwent combined procedures to assess the robustness of findings.

All statistical tests were 2-tailed, and P-values of <0.05 were considered significant. For post hoc and multiple comparisons, adjusted P-values were reported where applicable. Effect sizes were calculated to assess the magnitude of observed differences (Cohen d for continuous variables and Cramér V for categorical variables).

RESULTS

Patient demographics and baseline characteristics

A total of 315 patients who underwent surgery for HD were included in the study after excluding those who did not meet the eligibility criteria. Of these, 239 patients (75.9%) were male, with a mean age of 43.7±11.7 years. Patients who underwent combined procedures were categorized according to the more invasive technique (Fig. 1). The distribution of patients was 207 (65.7%) in the excisional group, 30 (9.5%) in the fixative group, and 78 (24.8%) in the ablative group.

Within the excisional group, 105 patients underwent vessel sealer hemorrhoidectomy, 59 underwent the Milligan-Morgan technique, and 43 underwent the Ferguson technique. In the fixative group, 25 patients were treated with HAL+mucopexy and 5 with the Longo technique. Demographics and baseline clinical characteristics were comparable across groups, except for sex distribution, with a significantly higher proportion of male patients in the ablative group compared with the other groups (P=0.026) (Table 2).

Preoperative symptoms and physical examination

Tenesmus was reported significantly more often by patients in the excisional group than in the other groups (P=0.011). Prolapse was significantly more common in the excisional and fixative groups than in the ablative group (P<0.001). A significant difference was also observed in the distribution of Goligher grades across groups (P<0.001). Specifically, grade III was more frequent in both the ablative and excisional groups, whereas grade IV predominated in the fixative group (Table 3).

Operative outcomes and techniques

Significant differences were observed between groups in terms of anesthesia type and use of perianal local anesthetics (both P<0.001). The requirement for narcotic analgesics was significantly lower in the ablative group compared with the excisional group (P<0.001) (Table 4).

Postoperative complications

Overall, postoperative complications were uncommon. However, compared with the excisional and ablative groups, the fixative group had a significantly higher incidence of urinary retention (10% vs. 1.9% in other groups, P=0.006) and a longer hospital stay (P<0.001) (Table 4). Postoperative bleeding was observed in 4 patients (1.9%) in the excisional group, whereas no cases were reported in either the fixative or ablative groups. No patients in any group required reoperation.

Patient-reported outcome measures

Four PROMs were evaluated. HDSS, SHSHD, and VAS scores were comparable among the 3 groups at all time points, except for preoperative HDSS. Preoperatively, HDSS were significantly higher in the excisional and fixative groups compared with the ablative group (P=0.006). PSS were similar across groups at both postoperative day 7 and postoperative week 6. In addition, changes over time in all PROMs were comparable across the 3 groups (Table 5, Fig. 2).

Subgroup analyses

PROMs were further analyzed within groups according to presenting symptoms and disease grade. No significant differences were detected, except among patients with grade II HD, where those treated with ablative procedures reported significantly higher satisfaction than patients in the excisional or fixative groups (Figs. 3, 4).

Within the excisional group, subgroup analysis revealed consistent trends across Milligan-Morgan, Ferguson, and vessel sealer techniques, supporting the validity of combining these procedures into a single category for the main analysis (Supplementary Table 1). Similarly, within the fixative group, both HAL+mucopexy and Longo techniques demonstrated comparable outcomes, though the small sample size of the Longo subgroup (n=5) limited the ability to perform detailed statistical comparisons (Supplementary Table 2).

DISCUSSION

HD remains a prevalent anorectal disorder with a significant impact on patient quality of life. Although numerous surgical techniques are available, real-world evidence comparing their effectiveness and patient-reported outcomes remains scarce. This large-scale, multicenter cohort study aimed to address this gap by evaluating the comparative effectiveness of different surgical approaches for HD, assessed primarily through PROMs.

By prioritizing PROMs, this study provides a more comprehensive understanding of treatment effects on patient experiences and overall well-being. PROMs offer valuable insights that complement traditional clinical outcomes, allowing for a holistic assessment of treatment success [11, 12]. Our findings demonstrate that all 3 surgical approaches (excisional, fixative, and ablative) are effective in managing HD, resulting in comparable improvements in PROMs within the first 6 weeks after surgery.

These results highlight the shared effectiveness of the techniques in achieving the primary goals of HD treatment: symptom relief and patient satisfaction. While overall outcomes were similar, the findings also underscore the importance of tailoring surgical choice to patient-specific factors. Considerations such as disease severity, symptom profile, and comorbidities may guide the selection of the most appropriate intervention.

Contrary to expectations, this study shows that traditional excisional methods remain a viable and effective option in daily practice. This finding is particularly notable given that the participating institutions were tertiary centers, where advanced techniques are widely available. When performed appropriately, excisional procedures can provide short-term outcomes comparable to minimally invasive alternatives with respect to symptom relief, patient satisfaction, and recovery.

Despite the perception that excisional techniques cause greater postoperative pain, our results suggest they may be as effective as other methods in long-term pain management. This finding reinforces the need for a patient-centered rather than technique-driven approach to HD management. Across participating centers, surgeons consistently favored excisional procedures, reflecting their continued relevance, especially for advanced disease.

Notably, significant differences were observed in baseline symptoms and examination findings between treatment groups. Patients with grade IV HD and prolapse were more frequently managed with fixative techniques (66.6%) than with excisional or ablative approaches. While pain, bleeding, itching, and soiling were comparable among groups, tenesmus was significantly more prevalent in the excisional group.

These patterns suggest that physicians tailored their treatment strategies to individual patient characteristics, aligning surgical decisions with disease severity and symptomatology. The higher use of fixative procedures in advanced disease highlights the importance of individualized decision-making in HD management. By recognizing the unique needs of each patient, clinicians can optimize treatment outcomes and improve patient satisfaction.

Postoperative pain management is a critical determinant of patient satisfaction and recovery. Although pain reduction occurred in all groups, patients undergoing excisional surgery required narcotics more frequently and for a longer duration compared with other groups. Previous studies have also indicated that excisional procedures may cause more immediate postoperative discomfort compared with newer methods such as ablative surgery [13, 14].

On the other hand, the greater reliance on general anesthesia in the ablative group may have contributed to the lower pain scores observed early postoperatively. Minimally invasive ablative procedures, including laser or radiofrequency ablation, are known to result in less tissue trauma and discomfort, often making them attractive options for patients seeking rapid recovery. However, by postoperative week 6, pain levels had converged across groups, suggesting that long-term pain profiles are similar regardless of surgical technique.

A notable finding of this study was the significantly higher satisfaction scores reported by patients with grade II HD who underwent ablative procedures. This result aligns with earlier studies suggesting that ablative approaches are especially suitable for early-stage disease with minimal prolapse, offering rapid recovery and reduced pain [15, 16]. The early postoperative results from this study reinforce the potential value of ablative surgery as a preferred option for grade II HD.

The risk profile of postoperative complications is a critical factor in determining the optimal surgical approach. The fixative group demonstrated a significantly higher incidence of postoperative urinary retention (10%), compared with 1.9% in other groups (P=0.006). This increased risk may reflect localized tissue edema or inflammation associated with fixative procedures, which can impair lower urinary tract function.

As reported in 2% to 10% of patients undergoing fixative techniques, several factors may contribute to the development of postoperative urinary retention [17–21]. Postoperative bleeding, although rare, represents another potentially important complication. It was observed in 1.9% of patients in the excisional group, while no cases occurred in the fixative or ablative groups [22, 23]. The overall low bleeding incidence across groups suggests that all 3 techniques can be considered to have acceptable safety profiles.

Patients in the fixative group also experienced significantly longer hospital stays than those in the excisional or ablative groups (P<0.001). While previous reports have associated ablative procedures with shorter hospitalization and faster recovery, the differences observed in our study may partly reflect variations in institutional care protocols and physician preferences across participating centers.

The remarkably low adoption of stapled hemorrhoidopexy (5 cases, 1.6%) in this multicenter cohort reflects a combination of factors, including the high cost of disposable staplers, technical learning curve requirements, and evolving evidence suggesting higher recurrence rates and unique complications compared with conventional procedures [24–26]. Despite these concerns, the Longo technique offers specific advantages, such as reduced postoperative pain, preservation of anal anatomy, and effectiveness in treating circumferential grade III–IV HD when appropriately indicated [27, 28]. The low utilization observed may represent a transitional phase in hemorrhoid surgery, in which traditional excisional procedures remain the gold standard, newer ablative methods provide effective and less complex alternatives, and economic considerations favor cost-efficient strategies. The decision between HAL+mucopexy and Longo techniques should therefore be individualized, taking into account surgeon expertise, patient anatomy, cost, and institutional practices rather than categorical preferences.

Based on our findings, several recommendations can be made to guide surgical decision-making. Ablative procedures (HeLP) appear most suitable for grade II–III HD with minimal prolapse, especially for patients who prioritize rapid recovery and minimal postoperative pain. In this study, grade II patients treated with ablative procedures reported significantly higher satisfaction (P<0.001), along with the lowest narcotic requirement (11.5% vs. 30.9% in the excisional group) and the shortest duration of analgesic use (1.09± 0.96 weeks). Importantly, no cases of urinary retention or postoperative bleeding were recorded in this group. Fixative techniques (HAL+mucopexy, Longo) produced optimal results in patients with grade IV HD and significant prolapse, with 66.6% of fixative procedures performed in this subgroup. However, patients undergoing fixative interventions should be counseled regarding the elevated risk of urinary retention (10% vs. 0% in other groups, P=0.006) and longer hospital stays (0.80±0.41 days vs. 0.47±0.5 days in the excisional group, P<0.001). Excisional procedures (Milligan-Morgan, Ferguson, vessel sealer) remained the most frequently selected approach (65.7% of cases) and were effective across all disease grades. They were particularly suitable for patients with grade III–IV HD accompanied by associated pathology such as skin tags or external hemorrhoids. Although excisional procedures were associated with greater narcotic use, this issue can be managed with appropriate patient counseling. Moreover, outcomes were consistent across the various excisional techniques.

Limitations

Several important limitations merit consideration when interpreting the results. First, the inclusion of different procedures within each surgical category (e.g., Milligan-Morgan vs. Ferguson in the excisional group) may obscure technique-specific effects. Although subgroup analyses demonstrated consistent trends, this heterogeneity remains a limitation. Second, PROM evaluations were not blinded to surgical technique, introducing the possibility of bias in subjective outcome measures. Third, while the study reflects routine clinical practice, the absence of standardized protocols introduces variability in operative techniques and postoperative care. Fourth, the 6-week outcomes provide only an interim assessment and do not capture long-term recurrence, durability, or late complications. Definitive conclusions await ongoing long-term follow-up. Fifth, as a nonrandomized, observational study, treatment allocation was subject to selection bias. Heterogeneity in sex, symptom distribution, and disease severity may have influenced outcomes. Although the study involved a large multicenter cohort, generalizability may be limited by regional differences in healthcare systems, patient populations, and surgical practices. Furthermore, PROMs were collected by telephone interview, which may introduce response bias. In addition, recall bias may have influenced the reporting of complications and satisfaction. Lastly, despite its nationwide scope, the study did not reach the anticipated sample size. Participating centers were not required to enroll all eligible patients, as data entry was time intensive. Given that hemorrhoid surgery is often performed as a day-case procedure, surgeons may not always have prioritized completing study forms, potentially limiting recruitment.

Conclusions

This real-world cohort study demonstrates that excisional, fixative, and ablative techniques are all effective in managing HD, providing comparable short-term improvements in symptoms and patient satisfaction. Despite the availability of alternative approaches, excisional techniques remain the most frequently employed, particularly in advanced disease and tertiary care settings. The limited use of stapled hemorrhoidopexy in this study likely reflects evolving evidence, cost considerations, and technical demands rather than intrinsic ineffectiveness. Future research should emphasize cost-effectiveness and long-term outcomes to better inform optimal technique selection.

Given the comparable efficacy of these techniques, the selection of a surgical technique for HD should be tailored to the individual patient, considering factors such as disease severity, patient preference, surgeon expertise, and institutional resources. Clinicians should consider a variety of factors, including patient preferences and surgeon expertise, when selecting the most appropriate surgical approach for each individual patient. Based on our findings, we recommend the following evidence-based approach to technique selection:

• Ablative procedures should be considered for grade II–III HD, particularly when rapid recovery and minimal postoperative pain are priorities.

• Fixative techniques remain valuable for grade IV HD with significant prolapse, although patients should be counseled about higher urinary retention risk and longer hospital stays.

• Excisional methods continue to be effective across all disease grades and remain the most versatile option, particularly when concomitant pathology exists.

Long-term follow-up data will be essential to fully understand the comparative effectiveness and durability of these surgical approaches. The choice of surgical technique may ultimately be individualized, considering factors such as disease severity, patient preference, and surgeon expertise.

ARTICLE INFORMATION

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: MK, MÖ, AT, NÇA; Data curation: MK, MÖ, AT, NÇA; Formal analysis: MK, MÖ, AT, NÇA; Investigation: all authors; Supervision: MK, MÖ, AT; Writing–original draft: MK, MÖ, AT, NÇA; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Additional information

This study was presented as an oral presentation at the 19th European Society of Coloproctology Annual Conference on September 27, 2024, in Thessaloniki, Greece

Correction

This article was corrected on June 18, 2026, to update the affiliation for author İlker Abcı.

Supplementary materials

Supplementary Table 1.

PROM scores in the excisional subgroup

ac-2025-00710-0101-Supplementary-Table-1.pdf

Supplementary Table 2.

PROM scores in fixative subgroup

ac-2025-00710-0101-Supplementary-Table-2.pdf

Supplementary materials are available from https://doi.org/10.3393/ac.2025.00710.0101.

Fig. 1.

Flowchart of the patient enrollment process. HAL, hemorrhoidal artery ligation; HeLP, hemorrhoidal laser procedure.

Fig. 2.

Patient-reported outcome measure scores across treatment groups over time. No significant differences were observed between groups. (A) Hemorrhoidal Disease Symptom Score (HDSS). (B) Short Health ScaleHD (SHSHD) score. (C) Patient Satisfaction Score (PSS). (D) Visual analog scale (VAS) score.

Fig. 3.

Comparison of patient-reported outcome measure score changes based on patients’ preoperative symptoms. (A) Hemorrhoidal Disease Symptom Score (HDSS). (B) Short Health ScaleHD (SHSHD) score. (C) Visual analog scale (VAS) score. (D) Patient Satisfaction Score (PSS). None of the comparisons demonstrated statistically significant differences between groups (all P≥0.05).

Fig. 4.

Comparison of patient-reported outcome measure score changes according to preoperative Goligher grades. (A) Hemorrhoidal Disease Symptom Score (HDSS). (B) Short Health ScaleHD (SHSHD) score. (C) Visual analog scale (VAS) score. (D) Patient Satisfaction Score (PSS). In grade II patients, the ablative group showed significantly lower PSS, indicating higher satisfaction, at postoperative weeks 1 and 6 compared with the excisional and fixative groups (P<0.001). No other comparisons showed statistically significant differences between groups (all P≥0.05).

Table 1.

Summary of the study protocol

Patient-reported outcome measure	Preoperative	Postoperative
Patient-reported outcome measure	Preoperative	Day 0–7	Day 7	Week 6	Month 12
Patient information	✓		✓	✓	✓
Disease-related information	✓		✓	✓	✓
Hemorrhoidal Disease Symptom Score	✓		✓	✓	✓
Short Health ScaleHD score	✓		✓	✓	✓
Visual analog scale score		✓	✓	✓	✓
Early/late postoperative complication		✓	✓	✓	✓
Recurrence				✓	✓
Patient Satisfaction Score				✓	✓

The study protocol includes preoperative data collection at participating centers and postoperative follow-up via telephone interviews conducted by a trained nurse at multiple timepoints; the 12-month evaluation has not been completed and is not presented.

Table 2.

Demographic and baseline clinical information of patients

Characteristic	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
Characteristic	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
Sex				0.026^*	0.772	0.009^*	0.036^*
Male	150 (72.5)	21 (70.0)	68 (87.2)
Female	57 (27.5)	9 (30.0)	10 (12.8)
Age (yr)	44.3±12.2	42.1±11.3	42.7±10.5	0.432
Body mass index (kg/m²)	26.1±3.9	25.1±3.1	27.1±4.6	0.764
Comorbidity	33 (15.9)	3 (10.0)	7 (9.0)	0.263
Anticoagulant use	8 (3.9)	1 (3.3)	3 (3.8)	0.992
Delivery history (n=76)^a	30/57 (52.6)	7/9 (77.8)	6/10 (60.0)	0.363

Values are presented as number (%) or mean±standard deviation.

^aOnly female patients were included.

^*P<0.05.

Table 3.

Preoperative symptoms and physical examination findings of patients

Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
Symptom
Pain	155 (74.9)	21 (70.0)	58 (74.4)	0.852
Itching	92 (44.9)	9 (30.0)	43 (55.1)	0.052
Bleeding	145 (70.0)	25 (83.3)	55 (70.5)	0.321
Prolapse	104 (50.2)	17 (56.7)	38 (48.7)	0.763
Soiling	82 (39.6)	11 (36.7)	31 (39.7)	0.951
Tenesmus	69 (33.3)	4 (13.3)	15 (19.2)	0.011^*	0.027^*	0.019^*	0.474
Constipation	103 (49.8)	11 (36.7)	40 (51.3)	0.344
Incontinence	14 (6.8)	2 (6.7)	8 (10.3)	0.615
Finding
Prolapse	94 (45.4)	20 (66.7)	26 (33.3)	<0.001^*	0.029^*	0.065	0.002^*
Skin tag	73 (35.3)	11 (36.7)	22 (28.2)	0.492
Thrombus	45 (21.7)	3 (10.0)	9 (11.5)	0.071
Bleeding	97 (46.9)	15 (50.0)	30 (38.5)	0.384
Soiling/discharge	70 (33.8)	13 (43.3)	19 (24.4)	0.124
Goligher classification				<0.001^*	0.060	<0.001^*	<0.002^*
Grade I	0 (0)	0 (0)	0 (0)
Grade II	19 (9.2)	2 (6.7)	9 (11.5)
Grade III	123 (59.4)	12 (40.0)	61 (78.2)
Grade IV	65 (31.4)	16 (53.3)	8 (10.3)

Values are presented as number (%).

^*P<0.05.

Table 4.

Perioperative and postoperative outcomes

Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
Staff surgeon	186 (89.9)	28 (93.3)	73 (93.6)	0.553
Duration of operation (min)	28.1±12	26.6±11.2	26.7±14.9	0.662
Anesthesia type				<0.001^*	0.032^*	<0.001^*	0.070
General	95 (45.9)	22 (73.3)	68 (87.2)
Spinal	94 (45.4)	8 (26.7)	7 (9.0)
Local and sedation	18 (8.7)	0 (0)	3 (3.8)
Perianal local anesthetic infiltration	33 (15.9)	14 (46.7)	30 (38.5)	<0.001^*	<0.001^*	<0.001^*	0.430
Pudendal block	8 (3.9)	4 (13.3)	5 (6.4)	0.061
Perioperative complication	0 (0)	0 (0)	0 (0)	NA
Narcotic analgesic	64 (30.9)	6 (20.0)	9 (11.5)	0.003^*	0.220	<0.001^*	0.250
Postoperative complication
Bleeding	4 (1.9)	0 (0)	0 (0)	0.354
Urinary retention	4 (1.9)	3 (10.0)	0 (0)	0.006^*	0.015^*	0.700	0.003^*
Infection (abscess)	0 (0)	0 (0)	0 (0)	NA
Reoperation	0 (0)	0 (0)	0 (0)	NA
Length of hospital stay (day)	0.47±0.5	0.80±0.41	0.37±0.48	<0.001^*	<0.001^*	0.580	<0.001^*
Duration of analgesic use (wk)	1.73±1.17	1.15±0.97	1.09±0.96	<0.001^*	0.044^*	<0.001^*	0.951
Local infiltration volume (mL)	10 (8–14)	-	5 (4–6)	NA
Pudendal block volume (mL)	20 (18–25)	20 (18–22)	-	NA

Values are presented as number (%), mean±standard deviation, or median (interquartile range).

NA, not applicable.

^*P<0.05.

Table 5.

PROM scores

PROM	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
PROM	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
HDSS (range, 0–20)
Preoperative	11.22±4.65	11.28±4.23	9.33±4.29	0.006^*	0.950	0.006^*	0.030^*
Postoperative day 7	12.63±4.11	10.73±4.85	11.28±5.08	0.124
Postoperative week 6	6.80±5.08	5.63±3.20	6.71±3.95	0.483
Change
Postoperative day 7 – preoperative	1.41±5.62	–0.55±5.80	1.95±6.95	0.211
Postoperative week 6 – preoperative	–4.42±5.55	–5.65±4.53	–2.62±6.04	0.154
SHSHD score (range, 0–21)
Preoperative	17.39±4.89	17.24±5.16	16.56±5.70	0.465
Postoperative day 7	9.48±4.86	8.33±4.27	8.69±4.20	0.332
Postoperative week 6	6.58±4.11	6.56±4.94	6.57±3.93	0.973
Change
Postoperative day 7 – preoperative	–7.91±6.41	–8.91±6.43	–7.87±6.88	0.614
Postoperative week 6 – preoperative	–10.81±6.00	–10.68±5.14	–9.99±6.37	0.795
VAS score (range, 0–10)
Preoperative	5.57±3.33	5.67±3.54	4.56±2.47	0.473
Postoperative day 7	2.83±2.79	2.40±1.64	1.79±1.78	0.284
Postoperative week 6	1.69±1.89	1.43±1.59	1.08±0.62	0.131
Change
Postoperative day 7 – preoperative	–2.74±3.81	–3.27±3.85	–2.77±2.49	0.722
Postoperative week 6 – preoperative	–3.88±3.46	–4.24±1.35	–3.48±3.56	0.596
PSS (range, 1–7)
Postoperative day 7	1.39±1.08	1.35±0.79	1.26±0.52	0.665
Postoperative week 6	1.34±0.83	1.39±1.30	1.14±0.34	0.383
Change (postoperative week 6 – postoperative day 7)	–0.05±0.94	0.02±1.09	–0.12±1.48	0.643

PROM, patient-reported outcome measure; HDSS, Hemorrhoidal Disease Symptom Score; SHSHD, Short Health ScaleHD; VAS, visual analog scale; PSS, Patient Satisfaction Score.

^*P<0.05.

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Patient-reported outcomes after hemorrhoid surgery: early results from a prospective, nationwide, real-world, cohort study on diverse approaches

Ann Coloproctol. 2025;41(6):573-585. Published online December 30, 2025

DOI: https://doi.org/10.3393/ac.2025.00710.0101

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Figure

Patient-reported outcomes after hemorrhoid surgery: early results from a prospective, nationwide, real-world, cohort study on diverse approaches

Fig. 1. Flowchart of the patient enrollment process. HAL, hemorrhoidal artery ligation; HeLP, hemorrhoidal laser procedure.

Fig. 2. Patient-reported outcome measure scores across treatment groups over time. No significant differences were observed between groups. (A) Hemorrhoidal Disease Symptom Score (HDSS). (B) Short Health ScaleHD (SHSHD) score. (C) Patient Satisfaction Score (PSS). (D) Visual analog scale (VAS) score.

Fig. 3. Comparison of patient-reported outcome measure score changes based on patients’ preoperative symptoms. (A) Hemorrhoidal Disease Symptom Score (HDSS). (B) Short Health ScaleHD (SHSHD) score. (C) Visual analog scale (VAS) score. (D) Patient Satisfaction Score (PSS). None of the comparisons demonstrated statistically significant differences between groups (all P≥0.05).

Fig. 4. Comparison of patient-reported outcome measure score changes according to preoperative Goligher grades. (A) Hemorrhoidal Disease Symptom Score (HDSS). (B) Short Health ScaleHD (SHSHD) score. (C) Visual analog scale (VAS) score. (D) Patient Satisfaction Score (PSS). In grade II patients, the ablative group showed significantly lower PSS, indicating higher satisfaction, at postoperative weeks 1 and 6 compared with the excisional and fixative groups (P<0.001). No other comparisons showed statistically significant differences between groups (all P≥0.05).

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Patient-reported outcomes after hemorrhoid surgery: early results from a prospective, nationwide, real-world, cohort study on diverse approaches

Patient-reported outcome measure	Preoperative	Postoperative
Patient-reported outcome measure	Preoperative	Day 0–7	Day 7	Week 6	Month 12
Patient information	✓		✓	✓	✓
Disease-related information	✓		✓	✓	✓
Hemorrhoidal Disease Symptom Score	✓		✓	✓	✓
Short Health ScaleHD score	✓		✓	✓	✓
Visual analog scale score		✓	✓	✓	✓
Early/late postoperative complication		✓	✓	✓	✓
Recurrence				✓	✓
Patient Satisfaction Score				✓	✓

Characteristic	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
Characteristic	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
Sex				0.026^*	0.772	0.009^*	0.036^*
Male	150 (72.5)	21 (70.0)	68 (87.2)
Female	57 (27.5)	9 (30.0)	10 (12.8)
Age (yr)	44.3±12.2	42.1±11.3	42.7±10.5	0.432
Body mass index (kg/m²)	26.1±3.9	25.1±3.1	27.1±4.6	0.764
Comorbidity	33 (15.9)	3 (10.0)	7 (9.0)	0.263
Anticoagulant use	8 (3.9)	1 (3.3)	3 (3.8)	0.992
Delivery history (n=76)^a	30/57 (52.6)	7/9 (77.8)	6/10 (60.0)	0.363

Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
Symptom
Pain	155 (74.9)	21 (70.0)	58 (74.4)	0.852
Itching	92 (44.9)	9 (30.0)	43 (55.1)	0.052
Bleeding	145 (70.0)	25 (83.3)	55 (70.5)	0.321
Prolapse	104 (50.2)	17 (56.7)	38 (48.7)	0.763
Soiling	82 (39.6)	11 (36.7)	31 (39.7)	0.951
Tenesmus	69 (33.3)	4 (13.3)	15 (19.2)	0.011^*	0.027^*	0.019^*	0.474
Constipation	103 (49.8)	11 (36.7)	40 (51.3)	0.344
Incontinence	14 (6.8)	2 (6.7)	8 (10.3)	0.615
Finding
Prolapse	94 (45.4)	20 (66.7)	26 (33.3)	<0.001^*	0.029^*	0.065	0.002^*
Skin tag	73 (35.3)	11 (36.7)	22 (28.2)	0.492
Thrombus	45 (21.7)	3 (10.0)	9 (11.5)	0.071
Bleeding	97 (46.9)	15 (50.0)	30 (38.5)	0.384
Soiling/discharge	70 (33.8)	13 (43.3)	19 (24.4)	0.124
Goligher classification				<0.001^*	0.060	<0.001^*	<0.002^*
Grade I	0 (0)	0 (0)	0 (0)
Grade II	19 (9.2)	2 (6.7)	9 (11.5)
Grade III	123 (59.4)	12 (40.0)	61 (78.2)
Grade IV	65 (31.4)	16 (53.3)	8 (10.3)

Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
Variable	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
Staff surgeon	186 (89.9)	28 (93.3)	73 (93.6)	0.553
Duration of operation (min)	28.1±12	26.6±11.2	26.7±14.9	0.662
Anesthesia type				<0.001^*	0.032^*	<0.001^*	0.070
General	95 (45.9)	22 (73.3)	68 (87.2)
Spinal	94 (45.4)	8 (26.7)	7 (9.0)
Local and sedation	18 (8.7)	0 (0)	3 (3.8)
Perianal local anesthetic infiltration	33 (15.9)	14 (46.7)	30 (38.5)	<0.001^*	<0.001^*	<0.001^*	0.430
Pudendal block	8 (3.9)	4 (13.3)	5 (6.4)	0.061
Perioperative complication	0 (0)	0 (0)	0 (0)	NA
Narcotic analgesic	64 (30.9)	6 (20.0)	9 (11.5)	0.003^*	0.220	<0.001^*	0.250
Postoperative complication
Bleeding	4 (1.9)	0 (0)	0 (0)	0.354
Urinary retention	4 (1.9)	3 (10.0)	0 (0)	0.006^*	0.015^*	0.700	0.003^*
Infection (abscess)	0 (0)	0 (0)	0 (0)	NA
Reoperation	0 (0)	0 (0)	0 (0)	NA
Length of hospital stay (day)	0.47±0.5	0.80±0.41	0.37±0.48	<0.001^*	<0.001^*	0.580	<0.001^*
Duration of analgesic use (wk)	1.73±1.17	1.15±0.97	1.09±0.96	<0.001^*	0.044^*	<0.001^*	0.951
Local infiltration volume (mL)	10 (8–14)	-	5 (4–6)	NA
Pudendal block volume (mL)	20 (18–25)	20 (18–22)	-	NA

PROM	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	P-value
PROM	Excisional group (n=207)	Fixative group (n=30)	Ablative group (n=78)	Overall	Excisional vs. Fixative	Excisional vs. Ablative	Fixative vs. Ablative
HDSS (range, 0–20)
Preoperative	11.22±4.65	11.28±4.23	9.33±4.29	0.006^*	0.950	0.006^*	0.030^*
Postoperative day 7	12.63±4.11	10.73±4.85	11.28±5.08	0.124
Postoperative week 6	6.80±5.08	5.63±3.20	6.71±3.95	0.483
Change
Postoperative day 7 – preoperative	1.41±5.62	–0.55±5.80	1.95±6.95	0.211
Postoperative week 6 – preoperative	–4.42±5.55	–5.65±4.53	–2.62±6.04	0.154
SHSHD score (range, 0–21)
Preoperative	17.39±4.89	17.24±5.16	16.56±5.70	0.465
Postoperative day 7	9.48±4.86	8.33±4.27	8.69±4.20	0.332
Postoperative week 6	6.58±4.11	6.56±4.94	6.57±3.93	0.973
Change
Postoperative day 7 – preoperative	–7.91±6.41	–8.91±6.43	–7.87±6.88	0.614
Postoperative week 6 – preoperative	–10.81±6.00	–10.68±5.14	–9.99±6.37	0.795
VAS score (range, 0–10)
Preoperative	5.57±3.33	5.67±3.54	4.56±2.47	0.473
Postoperative day 7	2.83±2.79	2.40±1.64	1.79±1.78	0.284
Postoperative week 6	1.69±1.89	1.43±1.59	1.08±0.62	0.131
Change
Postoperative day 7 – preoperative	–2.74±3.81	–3.27±3.85	–2.77±2.49	0.722
Postoperative week 6 – preoperative	–3.88±3.46	–4.24±1.35	–3.48±3.56	0.596
PSS (range, 1–7)
Postoperative day 7	1.39±1.08	1.35±0.79	1.26±0.52	0.665
Postoperative week 6	1.34±0.83	1.39±1.30	1.14±0.34	0.383
Change (postoperative week 6 – postoperative day 7)	–0.05±0.94	0.02±1.09	–0.12±1.48	0.643

Table 1. Summary of the study protocol

Table 2. Demographic and baseline clinical information of patients

Values are presented as number (%) or mean±standard deviation.

Only female patients were included.

P<0.05.

Table 3. Preoperative symptoms and physical examination findings of patients

Values are presented as number (%).

P<0.05.

Table 4. Perioperative and postoperative outcomes

Values are presented as number (%), mean±standard deviation, or median (interquartile range).

NA, not applicable.

P<0.05.

Table 5. PROM scores

PROM, patient-reported outcome measure; HDSS, Hemorrhoidal Disease Symptom Score; SHSHD, Short Health ScaleHD; VAS, visual analog scale; PSS, Patient Satisfaction Score.