Abstract
Background and Objectives: A number of published studies comparing transanal haemorrhoidal dearterialization (THD) and conventional haemorrhoidectomy (CH) have primarily focused on short-term outcomes, while data on long-term results remains scarce. This study aimed to compare Doppler-guided THD and CH with emphasis on both early and long-term postoperative results. Methods: This retrospective study included 336 patients who underwent CH (Group 1, n = 189) or Doppler-guided THD (Group 2, n = 147). The groups were compared according to demographic data, HD stage, symptoms, complications, duration of hospital stay, postoperative pain, patient satisfaction, and recurrence rates after 18 months of surgery. Results: There was no difference between groups regarding gender, although there were statistically significant distinctions in terms of disease stage and age (p < 0.001), with the emphasis that in CH group patients had advanced stage of disease and were older. THD was associated with significantly lower postoperative pain, with median visual analogue scale (VAS) scores on postoperative days 1, 2, and 7 of 5, 3, and 1, compared with 7, 5, and 3 after CH (p < 0.001). There was no difference in VAS on POD 30 between groups. Median hospital stay was significantly shorter after THD (1 vs. 3 days; p < 0.001). Patients undergoing CH required more analgesics, laxatives, and follow-up visits within the first postoperative month (p ≤ 0.008). Postoperative complications occurred in nine patients, without significant differences between groups. During the 18-month follow-up period, HD recurrence occurred in seven patients and was more frequent after THD. Additionally, two THD patients developed anal fissures. Conclusions: Doppler-guided THD is a safe and effective treatment for HD, providing reduced postoperative pain, faster recovery, and shorter hospitalization. Long-term outcomes were favourable in both groups, with a trend of lower recurrence rate in the CH group.
1. Introduction
Haemorrhoids are an integral part of the normal anatomy of the anal canal in healthy individuals and represent vascular cushions surrounding the anastomoses between the superior rectal artery and the superior, middle and inferior rectal veins [1]. They are considered to be an important contributor to the proper functioning of the faecal continence mechanism. The term “haemorrhoids” is usually used in everyday practice as an allusion to haemorrhoidal disease (HD). The most frequently reported symptom of internal haemorrhoids is bleeding, which is characterized as painless and usually associated with an act of defecation. In contrast, external haemorrhoids are commonly painful. The origin of this pain lies in the fact that the structures below the dentate line are being innervated by somatic fibres via the inferior rectal nerve; therefore, thrombosis of external haemorrhoids can inflict significant pain [1,2]. To assess the stage of HD, Goligher’s classification is most commonly used [2]. First- and second- degree HD are usually successfully treated with conservative treatment. This treatment is mainly based on dietary modification and improved hygienic habits [3]. Although increased fibre intake may reduce the risk of persistent symptoms and bleeding by 50%, it has had no effect on symptoms such as itching and pain and showed no influence on reducing the risk of prolapse [1,3]. The treatment of choice for the third- and fourth-degree HD, as well as for second-degree, which do not respond to conservative treatment, is conventional haemorrhoidectomy (CH) [1,4]. It was shown that although CH is the “gold standard”, the occurrence of postoperative complications is frequent. Among them, predominantly present are pain and discomfort, often necessitating the use of analgesics. In addition to the above-mentioned complications, the incidence of bleeding, faecal incontinence, anal stenosis, sphincter dysfunction and infection are also clinically significant [4,5]. Since its introduction, Doppler-guided haemorrhoidal artery ligation, also referred to as transanal haemorrhoidal dearterialization (THD) [6], has been evaluated in numerous studies comparing its surgical outcomes with those of CH. In the majority of them, only short-term postoperative effects were observed. To enable a more accurate analytical comparison between these two methods, further studies that enclose long-term results need to be undertaken [5,7]. Successful surgical treatment of HD is based on several key principles, including safety, efficacy, minimal postoperative pain, and the lowest possible rates of symptom recurrence and complication [8,9]. Therefore, the aim of our study was to compare the postoperative course of THD and CH in terms of patient contentment, postoperative pain, duration of hospital stay, complications, and recurrence rates in patients with third- and fourth-degree HD.
2. Materials and Methods
This retrospective study included patients who underwent surgical treatment for HD between January 2016 and October 2021. The degree of HD was determined using Goligher’s classification [2,10]. However, grade III of HD wase further subdivided according to the presence of an external component (A, none; B, one or few; and C, circumferential) based on the suggestions of Gerjy R et al. [11]. Inclusion criteria were second-, third-, and fourth-degree HD, both genders, age between 18 and 80 years, ability to understand the procedure, and provision of written informed consent for both procedures. Exclusion criteria included previous surgery for anal disorders and/or diseases, faecal incontinence, other active anorectal diseases, irritable bowel syndrome, and inflammatory bowel diseases. The diagnosis was established through physical examination and proctoscopy. In all patients over 50 years of age, as well as in younger patients with a family history of colorectal cancer in close relatives, a colonoscopy was performed as a standard screening method for colorectal cancer in our country. Six surgeons (M.B., S.D., I.P., M.J., M.M., and B.M.) examined the patients preoperatively and postoperatively and performed both techniques over the study period. The decision regarding the type of procedure depended on patient or surgeon preference. However, younger patients more frequently requested faster recovery and shorter hospital stay. As THD represents a minimally invasive technique, and based on our previous institutional experience demonstrating faster recovery and shorter hospitalization, this procedure was more often offered to younger patients. All surgeons had performed at least 30 supervised CH and THD operations before operating independently. All patients underwent the same perioperative management, which included identical preoperative protocol, and type of anaesthesia, as well as postoperative treatment—analgesic and follow-up regimen. Preoperative protocol was composed of administering enema and no antibiotic prophylaxis. All surgical procedures were conducted under general anaesthesia, without perianal block, in accordance with institutional standards. Postoperative analgesia consisted of intravenous Dexketoprofen 50 mg (single or double dose) or, alternatively, Metamizole 2 g. The follow-up regimen comprised adequate hygienic and dietary recommendations. The patients were placed in the lithotomy position. CH was performed without the use of a retractor and diathermy was utilized for both dissection and haemostasis. The majority of patients underwent open Milligan–Morgan haemorrhoidectomy, while a small number underwent the closed Ferguson technique [12]. For the THD procedure [13], a THD proctoscope (G.F Medical Division, Correggio, Italy) was used. Patients who underwent internal sphincterotomy during the procedure were excluded from the study. Pain was assessed using the visual analogue scale (VAS) based on the patient self-report, with pain intensity ranging from 0 to 10, where 0 represents the absence of the pain and 10 is the worst pain experienced. All patients were contacted by telephone once a week during the first 30 days postoperatively, in order to gather the data on whether or not the analgesics or laxatives were used, as well as the information about the patient’s general condition. At least one regular check-up was scheduled during the first 30 days postoperatively in all patients, with one proctoscopy in the outpatient clinic, but no earlier than three weeks after surgery. Patients who expressed the need for more than one check-up were examined and that was recorded as well. VAS pain scores were evaluated on postoperative days (POD) 1, 2, 7 and 30. Parameters of interest during the short-term follow-up (early postoperative period—30 days) included duration of hospital stay, need for analgesics (for at least 3 consecutive days after hospital discharge) and laxatives (at least 3 times after hospital discharge), postoperative complications (including postoperative bleeding requiring re-operation and anal fissure) and number of follow-up visits. Long-term follow-up over 18 months included scheduled clinical visits and proctoscopy at 3, 6, 12, and 18 months postoperatively. Long-term follow-up parameters included the occurrence of anal fissure and recurrence rate of HD. Recurrence was defined as the presence of internal or external haemorrhoids observed during control examinations with proctoscopy. Only patients who fulfilled all follow-up requirements were included in the analysis. Consequently, there was no loss to follow-up in the study cohort. Patients were divided into two groups: Group 1 included those who underwent CH and Group 2 included those who underwent Doppler-guided THD with mucopexy. All comparisons were made between these two groups.
Approval for this study was obtained from the local Ethics Committee of the Military Medical Academy (MMA) ref. No. 28/2015. All procedures performed in this study adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all individual participants included in the study.
A complete statistical analysis was performed using the IBM SPSS software, version 26.0. The Kolmogorov–Smirnov test was used to assess the normality of numerical data distribution. Numerical data are presented as mean values with standard deviation or median with interquartile range (25th–75th percentile), according to the normality of distribution for numerical data. The significance of differences in continuous variables was analysed using the parametric Independent Samples t-test or the nonparametric Mann–Whitney U test for comparisons between two groups. Categorical data are presented as absolute, and relative frequencies and the significance of differences between subgroups were assessed using the chi-square test. Spearman’s coefficient correlation was used to evaluate the relationships between variables. Statistical significance was defined as p < 0.05 for all comparisons. Univariate and multivariate logistic regression analyses were used to assess the predictive value of selected variables for surgical outcomes in both groups. A p-value less than 0.05 for variables in the univariate analysis was used for inclusion in the multivariate analysis. The results of the logistic regression analysis were presented as odds ratio with 95% confidence interval.
3. Results
The study included 336 patients who underwent operative treatment for HD grades II-IV. Group 1 included 189 patients (56.3%) who underwent CH, while Group 2 included 147 patients (43.7%) who underwent Doppler-guided THD with mucopexy. Demographic characteristics and grade of HD are shown in Table 1. Patients who underwent Doppler-guided THD with mucopexy were younger than those who underwent CH (46.73 ± 11.69 vs. 53.77 ± 12.84 years, p < 0.001). The majority of patients had grade III HD, with 267 patients distributed across both groups. Patients with higher grade of HD (IIIC and IV) underwent CH more often. A total of 82 patients with grade IIIC and IV of HD were operated by CH, compared to only 17 operated by Doppler-guided THD with mucopexy (p < 0.001). That was not the case for patients with grade II, IIIA and IIIB, where 130 of 237 patients underwent the Doppler-guided THD method. Notably, 83% of patients in Group 2 had IIIB grade of the disease. Out of 189 patients in Group 1, only 3 (1.6%) underwent Ferguson’s procedure, while the remainder underwent the Milligan–Morgan procedure.
Table 1.
Demographic data and grade of HD.
The clinical characteristics and early postoperative follow-up data are presented in Table 2.
Table 2.
Clinical characteristics and early postoperative follow-up data.
A significantly shorter duration of hospital stay was observed in Group 2 compared to Group 1 (p < 0.001). Median VAS pain scores differed on all PODs between groups (p < 0.001), except on POD 30, where patients in both groups reported similar pain levels. During the first 30 postoperative days, patients in Group 1 required significantly more analgesics than those in Group 2 (p = 0.008). A total of 81.5% of patients in Group 1 required laxatives compared with 59.2% of patients in Group 2 during the same period (p < 0.001). Overall, during the 30-day follow-up, postoperative complications occurred in nine patients, with no significant difference between groups (five versus four patients). In Group 1, five patients developed postoperative bleeding, all of whom underwent re-operation. In four patients, sutures were placed at previously ligated bleeding sites, while in one patient, haemostasis was achieved using diathermy and subsequent local tamponade with a haemostatic sponge. Two patients in Group 2 experienced postoperative bleeding; one required re-operation with additional suturing and, in the case of the other patient, a local tamponade in the anal canal with a haemostatic sponge was applied for bleeding control and definitive treatment. There was no occurrence of postoperative anal fissure in Group 1. Two patients in Group 2 developed acute anal fissures, which were managed conservatively. No infectious complications were observed in either group. The mortality rate was 0%. Patients in Group 1 required significantly more follow-up examinations during the first 30 postoperative days than those in Group 2 (p < 0.001). Long-term complications 18 months after surgery are summarized in Table 3.
Table 3.
Long-term outcome 18 months after surgery.
During the 18-month follow-up after surgery, a recurrence of HD occurred in seven patients. A higher incidence of HD recurrence was noted in Group 2. The results have shown 8 times higher rate of recurrence after THD. Among the six patients who experienced HD recurrence in Group 2, one initially presented with grade IIIC and five with grade IV of HD. Consequently, recurrence rates in Group 2 were 25% for grade IIIC and 38% for grade IV of HD over 18 months of follow-up. No patients in Group 1 developed anal fissure or internal haemorrhoids at the control examination 18 months after surgery. A significant negative correlation was found between the type of procedure and several variables: age of patient (Rho = −0.260, p ˂ 0.001), duration of hospital stay (Rho = −0.557, p ˂ 0.001), usage of analgesics during the first 30 postoperative days (Rho = −0.150, p = 0.006), usage of laxatives during the first 30 postoperative days (Rho = −0.246, p ˂ 0.001), and number of follow-up visits during the first 30 postoperative days (Rho = −0.678, p ˂ 0.001). The univariate logistic regression model showed that more frequent usage of analgesics was associated with postoperative complications and incidence of disease recurrence (8.352 (1.033–67.540), p = 0.047). Both the univariate logistic regression model (3.867 (1.862–8.034), p ˂ 0.001) and the multivariate logistic regression model (3.532 (1.691–7.375), p = 0.001) demonstrated that the number of follow-up visits was associated with postoperative complications and incidence of disease recurrence.
4. Discussion
In the modern era of surgical advancements, surgeons are faced with a challenge regarding both successful treatment and the greatest possible patient satisfaction, given that the fastest possible recovery with minimal pain endured is of paramount importance. Therefore, surgical treatment of HD poses a particular challenge. The surgical treatments for HD are mainly divided into two major groups: traditional (CH) and minimally invasive techniques. Traditional techniques have been modified to improve postoperative results, while, on the other hand, minimally invasive techniques are designed to lessen postoperative pain and injuries of the anal canal [5,7]. Since the introduction of THD, this method has been used to treat the prolapse and to improve long-term results of surgical treatment of HD [14]. Several meta-analysis on outcomes of THD versus other surgical methods for HD treatment have been published so far [5,15,16,17]. These studies mainly showed an equivalent effectiveness of THD and other procedures in HD treatment, but scarce data about long-term outcomes [15,16]. A randomized controlled trial on minimal open haemorrhoidectomy versus THD showed no differences in the impact on health-related quality of life, average and peak postoperative pain, recovery, or adverse events [9]; however, several limitations of this study have been reported, and they included the small number of patients, the small group of trained surgeons, and the follow-up period of 12 months. Our study included 336 consecutive patients who were operated on by experienced surgeons for both THD and CH. Our findings confirm that although CH remains the most definitive surgical option for advanced HD, THD offers clear early postoperative advantages, consistent with trends in contemporary minimally invasive anorectal surgery.
Patients undergoing THD experienced significantly less postoperative pain during the first postoperative week, shorter hospitalization, reduced need for analgesics and laxatives, and fewer postoperative visits compared with those treated by CH. These findings align with previously published meta-analyses and randomized studies, which consistently report reduced postoperative discomfort and faster recovery with THD [5,8,9,15,16,17]. Rørvik et al. demonstrated no major differences between minimal open haemorrhoidectomy and THD in long-term quality-of-life outcomes, but, similarly, noted reduced postoperative discomfort in the early recovery period [9]. The reduced tissue-trauma characteristic of THD likely accounts for these findings, as the procedure avoids excisional injury to the anoderm and preserves the physiological haemorrhoidal cushions [6,13].
Complications in both groups were uncommon, with no significant difference in overall rates. Postoperative bleeding requiring re-operation occurred in both groups, but remained low, consistent with previous reports, and highlights the trade-off between durability and invasiveness of excisional procedures [7,14,15,16,17]. Notably, acute anal fissure occurred only in the THD group, although the incidence was minimal and managed conservatively. Acute anal fissure following THD is a recognized but relatively uncommon complication, and is usually managed conservatively [18]. Although the precise pathophysiology is not well defined, it may be related to mucopexy, proctoscope manipulation, or internal anal sphincter spasm after the procedure. The absence of anal stenosis, incontinence, or infectious complications in both groups aligns with modern refinements in perioperative care and surgical technique. The safety profile of THD observed here is also in accordance with earlier prospective studies reporting very low complication rates and negligible sphincter-related morbidity [14].
Despite the increased comfort associated with THD, recurrence rates remain the major concern of this technique. In our study, recurrence occurred in 4.1% of patients in the THD group versus only 0.5% in the CH group at 18 months, which is 8 times higher. A recent meta-analysis published in 2024 by Jee et al., which included a total of six randomised control trials encompassing 465 patients treated for HD, has also shown that the THD was associated with a higher recurrence rate compared to CH. Based on the results shown in the aforementioned meta-analysis, as well as in our research, it cannot be disputed that THD has proven to be an effective technique for treating patients with HD. However, future prospective studies should focus on clarifying long-term recurrence rates. Although the absolute number of recurrences was low, this difference supports the prevailing view that CH provides the most durable anatomical correction, particularly in cases with high-grade prolapse [19,20]. Recurrence rates for the THD group were 25% for grade IIIC and 38% for grade IV of HD over 18 months of follow-up. These findings suggest a therapeutic limitation of the THD procedure in advanced prolapse and in long-term outcomes. Previous systematic reviews have reported recurrence rates ranging from 3% to 17% after THD, depending on follow-up duration, surgical expertise, and the degree of HD [14,15,16,17]. Our recurrence rate in the THD group is at the lower end of that range, likely reflecting the surgeon’s experience and patient selection. The high proportion of grade IIIB cases in the THD group and the preferential use of CH for more advanced grades (IIIC and IV) in our cohort further highlight the importance of prolapse severity in determining long-term success. Indeed, the present results reinforce observations from Gerjy et al. stating that prolapse grade is a more reliable predictor of symptom burden and recurrence risk than traditional classification alone [11].
The correlation analysis revealed that the need for analgesics, laxatives, and number of postoperative follow-up visits was significantly associated with the type of surgery, confirming that CH necessitates more intensive postoperative support. Logistic regression demonstrated that analgesic use and number of visits were also associated with postoperative complications and recurrence. The association between postoperative analgesic use and disease recurrence observed in our logistic regression analysis should be interpreted with caution. Persistent postoperative pain may indicate ongoing local inflammation, residual prolapse, or increased sphincter tone, all of which could be associated with a higher likelihood of symptom persistence or recurrence. Additionally, patients requiring prolonged analgesic use may represent a subgroup with more complex disease anatomy or higher baseline symptom severity. Therefore, analgesic use should be viewed as a clinical indicator of postoperative burden, rather than an independent predictor of recurrence. Prospective studies incorporating objective anatomical and functional assessments are needed to further clarify this relationship.
Our study has several strengths. It includes one of the largest single-centre series comparing THD with CH, with all procedures performed by experienced surgeons who had completed a standardized training threshold. The follow-up period of 18 months provides insight into both early and intermediate-term outcomes, addressing a limitation common in earlier studies that reported only short-term effects [5,15,16,17].
However, several limitations must be acknowledged. The retrospective design introduces potential selection bias, particularly regarding surgeon and patient preference for procedure type. This has resulted in a baseline imbalance between groups in terms of age and stage of HD. These characteristics could represent potential confounders affecting the outcomes. Therefore the results cannot be completely attributed to the surgical technique alone. Although this reflects real-world decision-making, randomized allocation would provide stronger evidence. Additionally, the follow-up period, while longer than many prior studies, may still be insufficient to fully assess late recurrence, particularly for THD. Finally, patient-reported outcomes such as quality of life or return to normal activity were not systematically collected in this retrospective study, and therefore could not be reliably analysed. Future prospective studies should incorporate standardized functional recovery metrics to better capture this aspect of postoperative benefit.
Overall, our results suggest that both CH and THD are safe and effective treatments for HD grades II-IV when performed by experienced surgeons. THD offers clear advantages in early postoperative recovery, reduced pain, and faster return to normal function. CH remains associated with lower recurrence, particularly for high-grade prolapse (IIIC-IV), underscoring its role as the most definitive procedure for advanced disease. A tailored, patient-centred approach—taking into account prolapse grade, symptom severity, expectations regarding recovery, and willingness to accept recurrence risk—is essential for optimal surgical decision-making.
Future prospective randomized trials with longer follow-up and standardized functional outcome measures are necessary to further clarify the optimal indications for each procedure and to establish long-term comparative durability.
5. Conclusions
Both THD and CH proved to be safe and effective surgical treatments for HD. THD offered significant advantages in the early postoperative period, including reduced pain, shorter hospitalization, decreased need for analgesics and laxatives, and fewer follow-up visits. Although, a higher number of recurrence was recorded in the THD group compared to CH, THD still showed good long-term results. However, this difference did not reach statistical significance, and should be interpreted in the context of the non-randomized study design and differences in baseline group characteristics. These findings highlight the importance of individualized treatment selection. THD is an appropriate option for patients prioritizing rapid recovery and minimal postoperative discomfort, whereas CH could be more suitable for higher-grade HD where long-term anatomical correction is essential. Further prospective studies with longer follow-up, randomization and standardized criteria for choice of technique are warranted to refine indications and optimize outcomes in surgical management of HD.
Author Contributions
Conceptualization, M.B., I.L. and M.M.; methodology, M.Š., M.B., L.Đ. and B.M.; formal analysis, S.D., R.P., N.R., M.M. and D.I.; investigation, I.P., D.I., I.M. and M.J.; writing—original draft preparation, M.B., R.P., L.Đ., N.R. and I.P.; writing—review and editing, M.B., B.M., S.D., M.J. and I.M.; supervision, M.B., I.L. and M.Š. All authors have read and agreed to the published version of the manuscript.
Funding
No external funding influenced study design, data collection, analysis, interpretation, or the decision to submit.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the Military Medical Academy, University of Defence, Belgrade, Serbia, ref. No. 28 on the 16 April 2015.
Informed Consent Statement
Written informed consent has been obtained from the patients in this study and can be provided upon request.
Data Availability Statement
All data generated or analysed during this study are available upon request from the corresponding author due to privacy and ethical restrictions.
Conflicts of Interest
The authors declare no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| THD | Transanal haemorrhoidal dearterialization |
| CH | Conventional haemorrhoidectomy |
| HD | Haemorrhoidal disease |
| VAS | Visual analogue scale |
| POD | Postoperative days |
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