Thanat Tantinam; Pawit Sutharat; Suwan Sanmee; Ekkarin Supatrakul; Kullawat Bhatanaprabhabhan; Boonchai Ngamsirimas; Nataphon Santrakul; Rangsima Thiengthiantham; Punnawat Chandrachamnong

doi:10.3393/ac.2025.00458.0065

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Original Article Anorectal benign disease Propensity score–matched comparative study of radiofrequency ablation (with the Rafaelo device) versus hemorrhoidectomy for the treatment of grades II–III internal hemorrhoids: Thanat Tantinam^1,2,3, Pawit Sutharat³, Suwan Sanmee³, Ekkarin Supatrakul³, Kullawat Bhatanaprabhabhan², Boonchai Ngamsirimas², Nataphon Santrakul², Rangsima Thiengthiantham², Punnawat Chandrachamnong²; Annals of Coloproctology 2025;41(5):409-416.
DOI: https://doi.org/10.3393/ac.2025.00458.0065
Published online: September 30, 2025

¹Surgical Unit, Phatthalung Hospital, Phatthalung, Thailand

²Division of Colorectal Surgery, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand

³Division of Colorectal Surgery and Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Correspondence to: Thanat Tantinam, MD Surgical Unit, Phatthalung Hospital, 421 Rames Rd, Phatthalung 93000, Thailand Email: b.thanat@gmail.com

• Received: April 12, 2025 • Revised: May 18, 2025 • Accepted: May 18, 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
REFERENCES

Abstract

Purpose
Hemorrhoidal disease impacts quality of life, with hemorrhoidectomy being the standard treatment for grades II–III hemorrhoids. Radiofrequency ablation (RFA) using the Rafaelo technique offers a less invasive alternative; however, comparative data remain limited. This study evaluated short-term outcomes following RFA versus conventional hemorrhoidectomy.
Methods
A single-center retrospective cohort study was conducted at a medical university hospital in Thailand, involving patients who underwent either RFA or hemorrhoidectomy between January 2023 and September 2024. Propensity score matching was utilized to minimize selection bias. Primary outcomes were postoperative pain and opioid consumption.
Results
After propensity score matching, 102 patients were analyzed (51 patients in each group). Baseline characteristics were well-balanced between the 2 groups. The RFA group had higher pain scores at 8 hours postoperatively (1 vs. 0, P=0.002) but lower scores at 20 hours (0 vs. 1, P<0.001). Opioid consumption was significantly lower in the RFA group (9.8% vs. 31.4%, P=0.007), with a reduced morphine-equivalent dose (0.7 mg vs. 3.5 mg, P=0.003). Additionally, the RFA group had a shorter operative time (20 minutes vs. 30 minutes, P<0.001) and less intraoperative blood loss (0 mL vs. 5 mL, P<0.001). Hospital stays and complication rates were comparable between groups.
Conclusion
RFA resulted in improved postoperative pain control, reduced opioid use, shorter operative duration, and decreased blood loss compared to hemorrhoidectomy, with similar hospital stay durations and complication rates.
Keywords: Hemorrhoids; Hemorrhoidectomy; Radiofrequency ablation

INTRODUCTION

Hemorrhoidal disease (HD) is among the most common anorectal conditions, with reported prevalence rates ranging from 2.9% to 29.7% in the general population [1, 2]. The pathophysiology of HD primarily involves abnormal dilation and distortion of vascular channels within the hemorrhoidal plexus [3, 4]. Consequently, treatment strategies target these underlying vascular abnormalities. The management of HD is guided by symptom severity and hemorrhoidal grade [5], with therapeutic options spanning minimally invasive office-based procedures to surgical excision. Both conservative and surgical interventions are available for grades II–III internal hemorrhoids [6], and hemorrhoidectomy remains the standard treatment [7]. Although hemorrhoidectomy is highly effective, it frequently causes significant postoperative pain and increases complication risks [8, 9]. Thus, investigating less invasive alternatives is essential to enhance patient comfort and minimize morbidity.

Radiofrequency ablation (RFA) has emerged as a promising minimally invasive approach for treating complex HD [10]. The physiological mechanism of RFA involves delivering 4 MHz radiofrequency energy through a needle probe, causing targeted destruction of hemorrhoidal vascular tissue [11]. One of the most commonly adopted RFA techniques is the radiofrequency treatment of hemorrhoids under local anesthesia (Rafaelo, F Care Systems), which can be conducted with local anesthesia alone. This approach reduces postoperative pain and eliminates risks associated with more invasive anesthesia methods such as spinal or general anesthesia. Several studies have demonstrated the benefits of RFA, including enhanced patient recovery and reduced complication rates [11–16]. However, few comparative studies have directly assessed RFA outcomes relative to conventional hemorrhoidectomy.

This study aimed to compare short-term outcomes between RFA and conventional hemorrhoidectomy, evaluating their efficacy and safety as alternative treatments for HD. This study was designed as a retrospective analysis of patients treated after the initial implementation of RFA at Vajira Hospital (Bangkok, Thailand). Given the novelty of this procedure and the availability of high-quality electronic medical records, a retrospective approach allowed timely and pragmatic evaluation of early real-world outcomes. Moreover, financial and logistical constraints precluded conducting a prospective trial during the early adoption phase. Hence, a retrospective design was the most feasible method to gather initial comparative data and inform future studies.

METHODS

Ethics statement

The study was approved by the Institutional Review Board of Vajira Hospital (No. COA 156/2567). The requirement for informed consent was waived due to the retrospective nature of the study and the de-identification of patient data. The study was performed in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines [17].

Study design and participants

This retrospective cohort study was conducted at Vajira Hospital, a medical university in Thailand, by reviewing electronic medical records from January 2023 to September 2024. Patients aged 18 years or older who were diagnosed with grade II or III internal hemorrhoids and underwent either RFA or hemorrhoidectomy as the primary treatment were included. Patients were excluded if they required concomitant treatment for external hemorrhoids, had coexisting perianal diseases, a history of previous perianal surgery, were pregnant, or were diagnosed with inflammatory bowel disease.

Surgical procedures and perioperative management

All procedures were performed by 5 experienced colorectal surgeons. At our institution, the standard hemorrhoidectomy technique is the Ferguson closed hemorrhoidectomy. Patients diagnosed with grade II or III internal hemorrhoids were routinely counseled regarding both treatment options. However, the RFA procedure incurs additional out-of-pocket expenses due to the cost of specialized equipment and disposable probes. Therefore, RFA was offered to all eligible patients, and those who were able to afford the additional cost underwent RFA, whereas the remaining patients underwent conventional hemorrhoidectomy. The anesthesia type, either spinal anesthesia or perianal block, was collaboratively selected by the surgeon and anesthesiologist. Spinal anesthesia was administered by anesthesiologists when indicated, whereas perianal block was performed under total intravenous anesthesia to minimize patient discomfort. The local anesthetic solution for the perianal block consisted of 20 mL of a 1:1 mixture of 1% xylocaine with adrenaline and 0.5% bupivacaine. Before surgery, a proctoscope was inserted to evaluate the internal hemorrhoidal condition.

During hemorrhoidectomy, hemorrhoids were excised up to the pedicle using diathermy, with careful preservation of the intervening skin and anodermal bridges. The pedicle was ligated with absorbable sutures, and wounds were closed using either continuous or interrupted sutures, according to the surgeon’s preference. A Rafaelo device equipped with a disposable HPR45i probe (MedFocus Co Ltd) was utilized for the RFA cohort. Energy levels between 2,000 to 3,000 J were applied based on hemorrhoid severity. The probe was inserted 5 to 10 mm into the target hemorrhoidal tissue at approximately a 30° angle, and radiofrequency energy was administered until the tissue displayed a whitish discoloration, indicating successful ablation. Hemostasis was achieved by applying cold saline-soaked gauze, followed by coagulation when necessary.

Postoperatively, patients were monitored either in the general ward or in the postoperative recovery unit, depending on the type of anesthesia received. Routine multimodal analgesia was uniformly administered to both groups, including oral paracetamol 500 mg every 6 hours for the first 3 postoperative days, followed by as-needed administration. Nonsteroidal anti-inflammatory drugs, typically in the form of nonselective cyclooxygenase inhibitors (commonly naproxen 250 mg orally 3 times daily), were prescribed for 3 days and continued as needed. Intravenous opioid analgesia was administered every 3 to 4 hours for breakthrough pain.

Outcome measures

Patient demographic and clinical data collected included age, sex, body mass index (BMI), presence of comorbidities, American Society of Anesthesiologists (ASA) physical status, presenting symptoms, hemorrhoid grading, number of hemorrhoidal columns involved, and prior medical treatment history for HD. Pain scores were evaluated using the visual analog scale (VAS) at 4, 8, 16, and 20 hours postoperatively. Opioid consumption was documented and converted to morphine-equivalent doses (mg). Additional outcomes included operative time (minutes), estimated blood loss (mL), length of hospital stay (LOS; days), and postoperative complications.

Statistical analysis

Descriptive statistics were used to summarize patient characteristics. Continuous variables were presented as mean±standard deviation or median (interquartile range, IQR). Categorical variables were reported as frequencies and percentages. The paired t-test was used for normally distributed continuous variables, whereas the Wilcoxon rank sum test was applied to nonparametric variables. Categorical variables were compared using the chi-square test or the Fisher exact test, as appropriate. Univariate and multivariate logistic regression analyses were conducted to identify significant predictive factors, with results reported as odds ratios and 95% confidence intervals.

To reduce selection bias, propensity score matching (PSM) was performed using 1:1 nearest-neighbor matching without replacement. Patients who underwent RFA were matched with those who underwent hemorrhoidectomy based on propensity scores calculated via logistic regression models. Covariates included in the matching process were age, sex, BMI, comorbidities, presenting symptoms, ASA physical status, number of hemorrhoidal columns, and prior treatment history. Covariate balance was evaluated using standardized mean differences. Statistical analysis was conducted using R Studio ver. 2023.06.0+421 (Posit PBC), employing the MatchIt, dplyr, ggplot2, tableone, and epiDisplay packages. A significance level of P<0.05 was considered statistically significant, and no imputation methods were applied for missing data.

RESULTS

Patient characteristics

A total of 232 patients were included in the study before PSM; 83 (35.8%) underwent RFA, and 149 (64.2%) underwent conventional hemorrhoidectomy. After 1:1 nearest-neighbor PSM, 102 patients were included in the final analysis, with 51 patients in each treatment group (Table 1). The baseline characteristics of the matched cohorts were well-balanced, with no significant differences observed in age (50.4±14.1 years vs. 52.5±14.7 years, P=0.455), sex distribution (51% male in both groups, P>0.999), or BMI (22.4 kg/m² [IQR, 21.7–23.1 kg/m²] vs. 24.2 kg/m² [IQR, 20.4–27.0 kg/m²], P=0.119). There were also no significant differences between groups regarding the presence of underlying diseases (33.3% vs. 49.0%, P=0.108), ASA physical status (P=0.609), or presenting symptoms (P=0.625). Most patients presented with either prolapse (74.5% vs. 66.7%) or bleeding (23.5% vs. 29.4%). Grade III hemorrhoids were more common than grade II hemorrhoids in both cohorts (70.6% vs. 74.5%, P=0.657). In the RFA group, the mean energy applied per hemorrhoidal column was 1763.2 J.

Postoperative pain and opioid use

The VAS scores demonstrated a distinct pattern between the 2 groups (Fig. 1). Although both groups had similar median pain scores during the early postoperative period, their underlying distributions revealed important differences. At 4 hours postoperatively, both the RFA and hemorrhoidectomy groups had a median VAS score of 0 (P=0.023); however, the violin plot indicated greater variability and more extreme pain scores in the hemorrhoidectomy group, suggesting a broader range of patient experiences despite similar central tendencies. At 8 hours, pain scores remained slightly higher in the RFA group (1 [IQR, 0–2] vs. 0 [IQR, 0–0], P=0.002), yet this difference rapidly narrowed. By 20 hours postoperatively, pain trajectories favored the RFA group, which exhibited significantly lower pain scores (0 [IQR, 0–0] vs. 1 [IQR, 0–3], P<0.001) (Table 2) along with a notably narrower distribution of scores.

Opioid consumption was significantly lower in the RFA group than in the hemorrhoidectomy group (9.8% vs. 31.4%, P=0.007). Additionally, the median morphine-equivalent dose was significantly lower in the RFA group (0.7 mg [IQR, 0.7–2.0 mg] vs. 3.5 mg [IQR, 3.0–3.9 mg], P=0.003) (Fig. 2).

Operative details and complications

The type of anesthesia varied significantly between groups. All patients in the RFA group (100%) underwent a perianal block, whereas 82.4% of those in the hemorrhoidectomy group received spinal anesthesia (P<0.001). The operative time was significantly shorter in the RFA group than in the hemorrhoidectomy group (20 minutes [IQR, 16–25 minutes] vs. 30 minutes [IQR, 25–40 minutes], P<0.001). Estimated blood loss was also significantly lower in the RFA group (0 mL vs. 5 mL, P<0.001). There were no significant differences in postoperative complications between groups (P=0.243). Acute urinary retention (AUR) occurred in 3 patients (5.9%) in the hemorrhoidectomy group, while no cases were reported in the RFA group. LOS was similar between groups, with a median duration of 1 day in both cohorts (P=0.392) (Table 3).

DISCUSSION

Several recent studies have reported outcomes of RFA for HD, primarily from case series [8–11, 16, 18]. These studies suggest that RFA is an effective alternative to hemorrhoidectomy, even in complex cases [9]. RFA has been shown to reduce postoperative pain [8, 10] and improve overall quality of life [8, 11], with a low incidence of postprocedural complications [16]. However, the postoperative pain scores reported in these studies varied, ranging from 0 to 2.5 [10, 16]. Despite multiple case series documenting the efficacy of RFA for HD, well-designed, direct comparative studies between RFA and hemorrhoidectomy remain limited.

The few available comparative studies, such as those conducted by Gupta [19, 20] in India, had limitations in design and sample size. These studies, each involving fewer than 30 patients per group, compared RFA with Milligan-Morgan open hemorrhoidectomy and did not utilize the Rafaelo device. Despite these limitations, RFA demonstrated superior outcomes regarding postoperative pain, operative time, LOS, time to return to work, and complication rates. Our findings align with these previous studies, indicating that RFA significantly outperformed hemorrhoidectomy concerning postoperative pain management, opioid use, operative time, and estimated blood loss.

In our study, both groups exhibited low short-term postoperative pain scores (within 20 hours postoperatively). A VAS score below 3 is considered acceptable for postoperative pain [21], and patients in both groups met this threshold. This finding can likely be attributed to aggressive multimodal analgesia protocols combined with breakthrough opioid administration.

Importantly, the RFA group demonstrated a 1-point lower VAS score than the hemorrhoidectomy group (0 vs. 1, P<0.001). Although seemingly modest, this difference is clinically meaningful, meeting the minimally clinically important difference (MCID) for acute postoperative pain, reported as ranging from 1.0 to 1.5 points in the literature [21, 22]. These results indicate that RFA provides not only statistically significant but also clinically relevant improvement in short-term postoperative pain. Additionally, opioid consumption was substantially lower in the RFA group, further reinforcing RFA’s superior pain control efficacy. Given the contemporary focus on opioid-sparing strategies in postoperative care, this finding positions RFA as a favorable treatment alternative.

We acknowledge that some VAS pain scores were missing, particularly in the hemorrhoidectomy group. Subgroup analysis indicated that missing pain score data occurred with both spinal and perianal anesthesia patients. For instance, at 16 hours postoperatively, data were missing for 47.6% of spinal anesthesia patients and 22.2% of perianal anesthesia patients. This suggests that missing data were not exclusively associated with anesthesia type. Rather, it may reflect inconsistent pain documentation during off-hours or among patients with minimal symptoms who declined reassessment. Notably, the RFA group consistently had lower rates of missing data. A plausible explanation is that these patients belonged to a previously reported case series, resulting in more rigorous documentation practices. This discrepancy may represent a reporting bias and warrants consideration.

Our results also support the procedural efficacy of RFA. Consistent with prior research, RFA resulted in significantly shorter operative time (20 minutes vs. 30 minutes, P<0.001) and minimal blood loss (0 mL vs. 5 mL, P<0.001). These advantages further confirm RFA's efficiency and safety as a minimally invasive technique.

Although perianal block anesthesia was increasingly adopted for hemorrhoidectomy patients in our study, 82.4% of these patients still underwent spinal anesthesia. Perianal block eliminates risks associated with spinal anesthesia, such as postdural puncture headache, AUR, and hemodynamic instability. This discrepancy in anesthesia methods may have influenced short-term outcomes, particularly regarding early postoperative pain and AUR. Spinal anesthesia provides prolonged analgesia during the early postoperative period, potentially affecting early postoperative pain scores, and is also a recognized risk factor for AUR. Although PSM was employed to minimize baseline differences, anesthesia type was not included as a matching covariate, potentially introducing residual confounding. Due to the limited number of hemorrhoidectomy patients receiving perianal block, subgroup analysis stratified by anesthesia type was not feasible. We acknowledge this as a limitation and recommend future prospective studies incorporate anesthesia type in their design and analysis to clearly isolate the effects of the surgical technique.

Although our study did not identify a statistically significant difference in postoperative complication rates between groups (P=0.243), no postoperative complications were observed in the RFA group, whereas 3 patients (5.9%) in the hemorrhoidectomy group developed AUR. This supports the favorable safety profile of RFA, particularly regarding reduced urinary complications commonly associated with spinal anesthesia.

Additionally, the LOS was similar between the groups (median, 1 day; P=0.392), likely influenced by institutional policies favoring same-day hemorrhoidal surgery. These findings suggest that despite being minimally invasive, RFA does not necessarily shorten LOS in settings where hemorrhoidectomy is already conducted as ambulatory surgery.

Limitations

Despite our efforts to minimize bias through PSM, this study had several limitations. First, its retrospective design introduced inherent biases, including selection bias and confounding factors potentially influencing outcomes. A randomized controlled trial is necessary to provide more robust evidence. Second, this study focused solely on short-term outcomes, primarily postoperative pain, opioid consumption, and immediate complications. However, HD is a chronic and recurrent condition, and short-term measures alone are insufficient to evaluate treatment durability fully. Long-term follow-up is necessary to assess recurrence rates, sustained symptom relief, and patient satisfaction—key indicators of clinical success. The absence of long-term data is a critical limitation; thus, future studies should prioritize extended follow-up to confirm the sustained efficacy and comparative benefits of RFA versus hemorrhoidectomy. Third, the single-center nature of our study limits external validity and generalizability to other populations. A multicenter study would increase the reliability and applicability of our findings. Finally, although our study demonstrated clinical benefits of RFA, it lacked a formal cost-effectiveness analysis. This is significant because the Rafaelo procedure requires specialized equipment and disposable probes, potentially imposing substantial economic burdens, particularly in low- and middle-income countries. Without clear cost-benefit data, widespread adoption of RFA may be hindered despite its clinical advantages. Future research should include multicenter randomized controlled trials, extended follow-up, and detailed cost-effectiveness evaluations to clearly define the clinical role of RFA in HD treatment.

Conclusions

Our findings suggest that RFA is an effective, minimally invasive alternative to hemorrhoidectomy for treating grades II–III internal hemorrhoids. It offers superior postoperative pain control, reduced opioid requirements, shorter operative duration, and fewer anesthesia-related complications. However, these conclusions derive from short-term outcomes. Given the chronic and potentially recurrent nature of HD, long-term follow-up is necessary to assess recurrence rates, sustained symptom relief, and patient satisfaction. Future randomized controlled trials with extended follow-up and cost-effectiveness analyses are warranted to validate our findings and clarify RFA’s long-term role in clinical practice.

ARTICLE INFORMATION

Conflict of interest

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

Funding

None.

Author contributions

Conceptualization: TT, PS, SS, ES, PC; Data curation: TT, PC; Formal analysis: TT, PC; Investigation: TT, SS, ES, KB, BN, NS, RT; Methodology: TT, SS, ES, PC; Project administration: PC; Resources: SS, ES, KB, BN, NS, RT; Software: TT, PC; Supervision: PS, SS, ES, KB, BN, NS, RT, PC; Validation: PS, PC; Visualization: TT; Writing–original draft: TT; 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 2025 American Society of Colon and Rectal Surgeons (ASCRS) Annual Scientific Meeting on May 11, 2025, in San Diego, CA, USA.

Fig. 1.

Violin plots illustrating the distribution of visual analog scale (VAS) pain scores stratified by surgical group and postoperative timepoint. Medians (represented by dots) and interquartile ranges (represented by bars) are overlaid. Due to kernel density smoothing, tails may visually extend slightly below a score of 0. P-values indicate statistically significant differences between the 2 groups at each specific postoperative timepoint.

Fig. 2.

Opioid use and morphine-equivalent dosage among patients undergoing radiofrequency ablation and hemorrhoidectomy. Bar plot shows the number of patients in each surgical group who required opioid analgesia. Overlaid boxplots indicate morphine-equivalent doses consumed, presented as median (interquartile range, IQR).

Table 1.

Patient characteristics before and after PSM

Characteristic	Before PSM (n=232)				After PSM (n=102)
Characteristic	RFA group (n=83, 35.8%)	Hemorrhoidectomy group (n=149, 64.2%)	P-value	SMD	RFA group (n=51, 50.0%)	Hemorrhoidectomy group (n=51, 50.0%)	P-value	SMD
Age (yr)	48.8±14.5	53.6±14.6	0.017	0.329	50.4±14.1	52.5±14.7	0.455	0.149
Sex			<0.001	0.515			>0.999	<0.001
Male	53 (63.9)	58 (38.9)			26 (51.0)	26 (51.0)
Female	30 (36.1)	91 (61.1)			25 (49.0)	25 (49.0)
Body mass index (kg/m²)	22.0 (20.2–23.0)	23.5 (21.5–26.6)	<0.001	0.539	22.4 (21.7–23.1)	24.2 (20.4–27.0)	0.119	0.330
Presence of underlying diseases	17 (20.5)	80 (53.7)	<0.001	0.732	17 (33.3)	25 (49.0)	0.108	0.323
ASA physical status			0.041	0.360			0.609	0.198
I	15 (18.1)	50 (33.6)			10 (19.6)	13 (25.5)
II	57 (68.7)	82 (55.0)			32 (62.7)	32 (62.7)
III	11 (13.3)	17 (11.4)			9 (17.6)	6 (11.8)
Presenting symptom			0.694	0.119			0.625	0.188
Prolapse	64 (77.1)	108 (72.5)			38 (74.5)	34 (66.7)
Bleeding	16 (19.3)	36 (24.2)			12 (23.5)	15 (29.4)
Pain/discomfort	3 (3.6)	5 (3.4)			1 (2.0)	2 (3.9)
Hemorrhoid severity			0.196	0.175			0.657	0.088
Grade II	21 (25.3)	27 (18.1)			15 (29.4)	13 (25.5)
Grade III	62 (74.7)	122 (81.9)			36 (70.6)	38 (74.5)
No. of hemorrhoidal columns			<0.001	0.643			0.701	0.312
1	1 (1.2)	17 (11.4)			1 (2.0)	3 (5.9)
2	19 (22.9)	51 (34.2)			16 (31.4)	19 (37.3)
3	50 (60.2)	75 (50.3)			29 (56.9)	26 (51.0)
4	8 (9.6)	5 (3.4)			2 (3.9)	2 (3.9)
5	5 (6.0)	1 (0.7)			3 (5.9)	1 (2.0)
Prior treatment	14 (16.9)	10 (6.7)	0.015	0.319	8 (15.7)	4 (7.8)	0.219	0.245

Values are presented as number (%), mean±standard deviation, or median (interquartile range). Percentages may not total 100 due to rounding.

PSM, propensity score matching; RFA, radiofrequency ablation; SMD, standardized mean difference; ASA, American Society of Anesthesiologists.

Table 2.

Pain scores and opioid use

Variable	RFA group (n=51)	Hemorrhoidectomy group (n=51)	P-value
Pain score (VAS)^a
At 4 hr	0 (0–2)	0 (0–0)	0.023^*
At 8 hr	1 (0–2)	0 (0–0)	0.002^*
At 16 hr	0 (0–1)	0 (0–3)	0.245
At 20 hr	0 (0–0)	1 (0–3)	<0.001^*
Opioid use	5 (9.8)	16 (31.4)	0.007^*
Morphine-equivalent dose (mg)	0.7 (0.7–2.0)	3.5 (3.0–3.9)	0.003^*

Values are presented as median (interquartile range) or number (%).

RFA, radiofrequency ablation; VAS, visual analog scale.

^aMissing data: RFA group, 1 (2.0%) at 4 hours, 2 (3.9%) at 8 hours, 1 (2.0%) at 16 hours, and 1 (2.0%) at 20 hours; hemorrhoidectomy group, 2 (3.9%) at 4 hours, 10 (19.6%) at 8 hours, 22 (43.1%) at 16 hours, and 10 (19.6%) at 20 hours.

^*P<0.05 (missing data were not imputed).

Table 3.

Operative details and complications

Variable	RFA group (n=51)	Hemorrhoidectomy group (n=51)	P-value
Anesthetic type			<0.001^*
Spinal block	0 (0)	42 (82.4)
Perianal block	51 (100)	9 (17.6)
Operative time (min)	20 (16–25)	30 (25–40)	<0.001^*
Estimated blood loss (mL)	0 (0–0)	5 (5–5)	<0.001^*
Complication			0.243
No	51 (100)	48 (94.1)
Yes (AUR)	0 (0)	3 (5.9)
Length of hospital stay (day)	1 (1–1)	1 (0–2)	0.392

Values are presented as number (%) or median (interquartile range).

RFA, radiofrequency ablation; AUR, acute urinary retention.

^*P<0.05.

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Propensity score–matched comparative study of radiofrequency ablation (with the Rafaelo device) versus hemorrhoidectomy for the treatment of grades II–III internal hemorrhoids

Ann Coloproctol. 2025;41(5):409-416. Published online September 30, 2025

DOI: https://doi.org/10.3393/ac.2025.00458.0065

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Propensity score–matched comparative study of radiofrequency ablation (with the Rafaelo device) versus hemorrhoidectomy for the treatment of grades II–III internal hemorrhoids

Fig. 1. Violin plots illustrating the distribution of visual analog scale (VAS) pain scores stratified by surgical group and postoperative timepoint. Medians (represented by dots) and interquartile ranges (represented by bars) are overlaid. Due to kernel density smoothing, tails may visually extend slightly below a score of 0. P-values indicate statistically significant differences between the 2 groups at each specific postoperative timepoint.

Fig. 2. Opioid use and morphine-equivalent dosage among patients undergoing radiofrequency ablation and hemorrhoidectomy. Bar plot shows the number of patients in each surgical group who required opioid analgesia. Overlaid boxplots indicate morphine-equivalent doses consumed, presented as median (interquartile range, IQR).

Fig. 1.

Fig. 2.

Propensity score–matched comparative study of radiofrequency ablation (with the Rafaelo device) versus hemorrhoidectomy for the treatment of grades II–III internal hemorrhoids

Characteristic	Before PSM (n=232)				After PSM (n=102)
Characteristic	RFA group (n=83, 35.8%)	Hemorrhoidectomy group (n=149, 64.2%)	P-value	SMD	RFA group (n=51, 50.0%)	Hemorrhoidectomy group (n=51, 50.0%)	P-value	SMD
Age (yr)	48.8±14.5	53.6±14.6	0.017	0.329	50.4±14.1	52.5±14.7	0.455	0.149
Sex			<0.001	0.515			>0.999	<0.001
Male	53 (63.9)	58 (38.9)			26 (51.0)	26 (51.0)
Female	30 (36.1)	91 (61.1)			25 (49.0)	25 (49.0)
Body mass index (kg/m²)	22.0 (20.2–23.0)	23.5 (21.5–26.6)	<0.001	0.539	22.4 (21.7–23.1)	24.2 (20.4–27.0)	0.119	0.330
Presence of underlying diseases	17 (20.5)	80 (53.7)	<0.001	0.732	17 (33.3)	25 (49.0)	0.108	0.323
ASA physical status			0.041	0.360			0.609	0.198
I	15 (18.1)	50 (33.6)			10 (19.6)	13 (25.5)
II	57 (68.7)	82 (55.0)			32 (62.7)	32 (62.7)
III	11 (13.3)	17 (11.4)			9 (17.6)	6 (11.8)
Presenting symptom			0.694	0.119			0.625	0.188
Prolapse	64 (77.1)	108 (72.5)			38 (74.5)	34 (66.7)
Bleeding	16 (19.3)	36 (24.2)			12 (23.5)	15 (29.4)
Pain/discomfort	3 (3.6)	5 (3.4)			1 (2.0)	2 (3.9)
Hemorrhoid severity			0.196	0.175			0.657	0.088
Grade II	21 (25.3)	27 (18.1)			15 (29.4)	13 (25.5)
Grade III	62 (74.7)	122 (81.9)			36 (70.6)	38 (74.5)
No. of hemorrhoidal columns			<0.001	0.643			0.701	0.312
1	1 (1.2)	17 (11.4)			1 (2.0)	3 (5.9)
2	19 (22.9)	51 (34.2)			16 (31.4)	19 (37.3)
3	50 (60.2)	75 (50.3)			29 (56.9)	26 (51.0)
4	8 (9.6)	5 (3.4)			2 (3.9)	2 (3.9)
5	5 (6.0)	1 (0.7)			3 (5.9)	1 (2.0)
Prior treatment	14 (16.9)	10 (6.7)	0.015	0.319	8 (15.7)	4 (7.8)	0.219	0.245

Variable	RFA group (n=51)	Hemorrhoidectomy group (n=51)	P-value
Pain score (VAS)^a
At 4 hr	0 (0–2)	0 (0–0)	0.023^*
At 8 hr	1 (0–2)	0 (0–0)	0.002^*
At 16 hr	0 (0–1)	0 (0–3)	0.245
At 20 hr	0 (0–0)	1 (0–3)	<0.001^*
Opioid use	5 (9.8)	16 (31.4)	0.007^*
Morphine-equivalent dose (mg)	0.7 (0.7–2.0)	3.5 (3.0–3.9)	0.003^*

Variable	RFA group (n=51)	Hemorrhoidectomy group (n=51)	P-value
Anesthetic type			<0.001^*
Spinal block	0 (0)	42 (82.4)
Perianal block	51 (100)	9 (17.6)
Operative time (min)	20 (16–25)	30 (25–40)	<0.001^*
Estimated blood loss (mL)	0 (0–0)	5 (5–5)	<0.001^*
Complication			0.243
No	51 (100)	48 (94.1)
Yes (AUR)	0 (0)	3 (5.9)
Length of hospital stay (day)	1 (1–1)	1 (0–2)	0.392

Table 1. Patient characteristics before and after PSM

Values are presented as number (%), mean±standard deviation, or median (interquartile range). Percentages may not total 100 due to rounding.

PSM, propensity score matching; RFA, radiofrequency ablation; SMD, standardized mean difference; ASA, American Society of Anesthesiologists.

Table 2. Pain scores and opioid use

Values are presented as median (interquartile range) or number (%).

RFA, radiofrequency ablation; VAS, visual analog scale.

Missing data: RFA group, 1 (2.0%) at 4 hours, 2 (3.9%) at 8 hours, 1 (2.0%) at 16 hours, and 1 (2.0%) at 20 hours; hemorrhoidectomy group, 2 (3.9%) at 4 hours, 10 (19.6%) at 8 hours, 22 (43.1%) at 16 hours, and 10 (19.6%) at 20 hours.

P<0.05 (missing data were not imputed).

Table 3. Operative details and complications

Values are presented as number (%) or median (interquartile range).

RFA, radiofrequency ablation; AUR, acute urinary retention.

P<0.05.