{"paper_id":"062fd463-fa24-433d-a6fa-99409853b8f4","body_text":"Determinants Influencing Decision-Making for Operative and Perioperative Management of Grade III and IV Hemorrhoidal Disease: Secondary Analysis of a Multicenter Nationwide Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Determinants Influencing Decision-Making for Operative and Perioperative Management of Grade III and IV Hemorrhoidal Disease: Secondary Analysis of a Multicenter Nationwide Prospective Cohort Study Metin Kement, Orhan Ali̇moglu, Hakan Baysal, Salih Tosun, Atif Tekin, and 20 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6981998/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2026 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: With multiple treatment options available for hemorrhoidal disease (HD), identifying factors that influence surgical and perioperative management decisions is essential, particularly in advanced cases. This study aimed to determine the patient and disease-related determinants affecting the choice of surgical technique and perioperative management in patients with Grade III and IV HD, thereby addressing inter-institutional variations in treatment approaches. Methods: A secondary analysis was performed on data from a nationwide, multicenter prospective cohort study. The study included 315 patients diagnosed with Grade III (72%) and Grade IV (28%) HD, with a mean age of 43.7 ± 11.4 years and a male predominance (76.7%). Preoperative data, including patient demographics, comorbidities (ASA scores), symptom severity, and clinical findings, were collected at participating governmental and private hospitals. Surgical techniques were classified as excisional or non-excisional, while anesthesia type, use of perianal or pudendal analgesia, and hospitalization duration were determined by the surgical teams. Hospital type was also recorded. Multivariable analyses were conducted to identify factors influencing the choice of surgical techniques, anesthesia, analgesia application, and the decision for outpatient procedures. Results: Multivariate analysis revealed that the presence of thrombosis significantly influenced the choice of surgical technique (OR: 7.2, CI: 2.8–12.7, p = 0.001), while hospital category also played an important role (OR: 5.1, CI: 2.7–9.7, p = 0.001). For anesthesia type, factors such as disease grade (OR: 3.3, CI: 1.6–6.7, p = 0.001), hospital category (OR: 9, CI: 4.1–19.9, p < 0.001), and surgical technique (OR: 6.8, CI: 3–15.3, p < 0.001) were significant determinants. The decision to use perianal or pudendal analgesia was influenced by hospital category (OR: 27.1, CI: 11.7–62.6, p < 0.001) and the presence of incontinence (OR: 0.2, CI: 0.04–0.93, p = 0.04). Outpatient management was associated with disease grade (OR: 2.3, CI: 1.1–4.8, p = 0.023), hospital category (OR: 2, CI: 1.2–3.2, p = 0.011), higher comorbidity (ASA ≥ 3, OR: 3.3, CI: 1.8–3.2, p = 0.007), and the selected surgical technique (OR: 3.1, CI: 1.6–5.8, p = 0.001). Conclusion: Significant inter-institutional variations exist in the management of advanced HD. Among various factors, the presence of thrombosis emerges as the predominant determinant in surgical decision-making, providing valuable insights for standardizing treatment protocols and reducing practice variability. Hemorrhoidal disease hemorrhoidectomy hemorrhoid surgery Figures Figure 1 INTRODUCTION Hemorrhoidal disease (HD) is a common anorectal condition with a significant impact on patient quality of life. Despite its prevalence, the management of HD exhibits considerable variability in clinical practice, influenced by diverse therapeutic approaches, regional healthcare systems, and evolving treatment technologies ( 1 – 5 ). The Goligher classification, a four-grade system for categorizing the severity of hemorrhoidal prolapse, is widely recognized as a crucial determinant in treatment decision-making, particularly in the selection of surgical technique ( 6 ). Current clinical guidelines recommend a range of surgical approaches for the management of Grade III and IV hemorrhoids, including excisional hemorrhoidectomy, stapled hemorrhoidopexy, doppler-guided hemorrhoidal artery ligation, and ablative techniques ( 7 ). The management of symptomatic hemorrhoids necessitates an individualized approach. Our findings support the established role of conventional hemorrhoidectomy, considered the gold standard for more symptomatic grade 3 and 4 hemorrhoids. Patients with higher HDSS and SHS-HD scores, indicative of more severe disease, were more likely to undergo excisional hemorrhoidectomy in our cohort, aligning with the recognized clinical practice for managing patients with significant symptoms ( 8 – 10 ). Each surgical modality presents distinct advantages and limitations with respect to postoperative pain, quality of life, recovery time, and cost ( 8 – 10 ). Despite advancements in surgical techniques, considerable variability exists in the perioperative management of HD across clinical settings. Prospective randomized trials have consistently demonstrated the superiority of several anesthetic approaches, including general anesthesia with local infiltration, over spinal anesthesia alone. Other applications include the use of adjunctive analgesia such as pudendal nerve block or perianal injections of local anesthetics for improved postoperative pain control ( 11 – 13 ). Advancements in surgical techniques, such as minimally invasive procedures and enhanced postoperative pain management, have made outpatient hemorrhoidectomy a feasible and increasingly common option ( 14 ). Despite the evidence supporting these practices, there is a significant gap in our understanding of their real-world application. This variability in clinical practice may be influenced by a multitude of factors, including institutional policies, surgeon expertise, patient preferences, and the characteristics of the healthcare system. However, the specific factors that drive clinician decision-making in the selection of these different management approaches remain largely unexplored. The significant variability in the management of HD across different settings highlights the crucial importance of conducting multicenter analyses to identify patterns, discrepancies, and ultimately establish best practices in the field. Utilizing data from a multicenter nationwide prospective cohort study, this study aims to investigate the factors that influenced surgical decision-making in the treatment of HD, including the choice of surgical techniques and the implementation of various perioperative applications. METHODS A prospective cohort study was conducted between July 2022 and July 2024 at 20 tertiary care or university hospitals across diverse regions at Türkiye (registered on ClinicalTrials.gov with the identifier number of NCT05429060). Istanbul Medipol University Research Committee granted the study and Institutional Ethics Committee approved the protocol (Protocol number: E-10840098-772.02-3634) in compliance with the Declaration of Helsinki. This study presents a secondary analysis of abstracted information to identify the factors influencing surgeons' preferences for surgical approaches. To ensure data homogeneity, we included only patients with grade 2 or 3 disease and centers that contributed at least 10 cases to the study. Patients aged 18 years and older who underwent surgery for symptomatic hemorrhoidal disease were included. Exclusion criteria included patients with concurrent proctological conditions such as fistulas, abscesses, and fissures; a history of prior hemorrhoid surgery; inflammatory bowel disease; pelvic or perineal radiation; previous perianal trauma or obstetric injury; and prior rectal surgeries for benign or malignant conditions. To ensure standardized treatment, all patients were required to undergo at least four weeks of conservative management prior to surgical intervention. Sigmoidoscopy was required for patients under 50, while colonoscopy was mandatory for those over 50 to rule out other potential pathologies. All perioperative process including surgical technique, anesthesia type, application of pudendal or perianal analgesic application and outpatient hospitalization was decided by the surgical teams or surgeons. Data collection included patient demographics, body mass index, anticoagulant use, comorbidities (American Society of Anesthesiology (ASA) Score), smoking, and delivery history. Surgical teams also recorded patient complaints (pain, itching, bleeding, prolapse, soiling, tenesmus, constipation, and incontinence), physical examination findings (prolapse, skin tags, thrombus, bleeding, soiling/discharge), and disease severity using the Golligher classification ( 6 ). Two different questionnaires were used for reporting patient reported outcome measures (PROMs). The severity of hemorrhoidal symptoms was assessed using the Hemorrhoidal Disease Symptom Score (HDSS), a 5-item scale with a possible range from 0 to 20 ( 15 ). Health-related quality of life associated with hemorrhoids was evaluated using the Short Health Scale-Hemorrhoidal Disease (SHS-HD), a 4-item scale with a possible range from 0 to 21 ( 16 ). The experience level of the operating surgeon, whether attending staff or supervised resident, was recorded. According to study protocol, perioperative management decisions, including surgical technique, anesthesia type, application of pudental analgesia or perianal analgesics, and time for discharge were left to the discretion of the surgical teams. Surgical techniques were categorized as excisional (Milligan-Morgan and Ferguson hemorrhoidectomy) or non-excisional (stapler hemorrhoidopexy, Doppler-guided hemorrhoidal artery ligation [HAL] with or without mucopexy, and laser [HeLP]). Other perioperative measures including anesthesia type (general, spinal/regional), the application of perianal anesthetics or pudendal block, and outpatient status following surgery were documented. The participating hospital where the surgery was performed, as well as hospital category (governmental or private), was recorded. Statistics All analyses were performed using SPSS version 26. Continuous variables were presented as mean ± standard deviation, and categorical variables as frequencies and percentages.Group comparisons were conducted using one-way ANOVA for normally distributed data and the Kruskal-Wallis test for non-normally distributed data. Categorical variables were analyzed using chi-square or Fisher’s exact tests, with adjusted residuals explored for significant associations.Binary logistic regression was used to identify factors influencing surgical and perioperative decisions. Variables with a univariate p < 0.2 were included in multivariate models. A p < 0.05 threshold was considered statistically significant. Multicollinearity was evaluated using. RESULTS Out of the 315 patients operated on across 20 participating centers, only 279 patients (88.6%) from 9 institutions were eligible for inclusion in the study. The mean age of patients was 43.7 ± 11.4 years with male majority (n = 214, 76.7%). All included centers were tertiary-level governmental (n = 6) or private (n = 3) institutions affiliated to universities or education and research hospitals, providing a consistent standard of care and resource availability. Grade III hemorrhoids were observed in 201 (72%) patients, and Grade IV in 78 (28%). Surgical procedures were performed in 170 (60.9%) patients at governmental hospitals and 109 (39.1%) at private institutions. Demographic and perioperative data for the cohort, encompassing both grade III and grade IV disease, are summarized in Table 1 . Table 1 Patient Characteristics and Perioperative Data for the Cohort Studied Parameters Grade III (n = 201) Grade IV (n = 78) Study Cohort (n = 279) Patient Characteristics Gender (male, %) 152(75.6) 62 (79.4) 214 (76.7) Age (mean years ±SD) 44.3±11.4 42±11.4 43.6±11.4 BMI (mean kg/m2 ±SD) 26.1±3.8 25.2±3.4 25.9±3.6 Comorbidity (ASA ≥ 3) (n, %) 23 (11.4%) 10 (12.8%) 33 (11.8) Anti-coagulant (n, %) 11 (3.9) Smoking (n, %) 61 (30.3%) 26 (33.3%) 87 (31.2) Delivery History n = 65 F (n, %) 25(51 of F) 10(62.5 of F) 35 (52.8) Patient Complaints Pain (n, %) 148 (73.6%) 58 (74.4%) 206 (73.8) Itching (n, %) 94 (46.8%) 33 (42.3%) 127 (45.5) Bleeding (n, %) 137 (68.2%) 57 (73.1%) 194 (69.5) Prolapse (n, %) 82 (40.8%) 56 (71.8%) 138 (49.5) Soiling (n, %) 73 (36.3%) 36 (46.2%) 109 (39.1) Tenesmus (n, %) 55 (27.4%) 24 (30.8%) 79 (28.3) Constipation (n, %) 99 (49.5%) 38 (48.7%) 137 (49.1) Incontinence (n, %) 13 (6.5%) 10 (12.8%) 23 (8.2) Physical Examination Findings Prolapse (n, %) 68 (33.8%) 53 (67.9%) 121 (43.4) Skin Tag (n, %) 61 (30.3%) 26 (33.3%) 87 831.2) Thrombus (n, %) 34 (16.9%) 19 (24.4%) 53 ( 19 ) Bleeding (n, %) 84 (41.8%) 41 (52.6%) 125 (44.8) Soiling/Discharge (n, %) 62 (31.0%) 29 (37.2%) 91 (32.6) PROMs Preop. SHS-HD(mean±SD) 16.5±5.3 18.1±5.0 16.9±5.2 Preop. HDSS (mean±SD) 10.5±4.7 10.7±4.1 10.6±4.5 Hosiptals Governmental Institutions #1 26 (12.9%) 6 (7.7%) 32 (11.4) #3 8 (4.0%) 2 (2.6%) 10 (3.6) #4 65 (32.3%) 8 (10.3%) 73 (26.1) #5 19 (9.5%) 10 (12.8%) 29 (10.4) #6 10 (5.0%) 6 (7.7%) 16 (5.7) #9 0 (0.0%) 10 (12.8%) 10 (3.6) Private Institutions #2 14 (7.0%) 9 (11.5%) 23 (8.2) #7 53 (26.4%) 20 (25.6%) 73 (26.1) #8 6 (3.0%) 7 (9.0%) 13 (4.7) Hospital Category Government 128 (63.7%) 42 (53.8%) 170 (60.9) Private 73 (36.3%) 36 (46.2%) 109 (39.1) Surgical Technique Excisional 129 (64.2%) 57 (73.1%) 186 (66.7) Non-Excisional 72 (35.8%) 21 (26.9%) 93 (33.3) Anesthesia Type General 132 (65.7%) 38 (48.7%) 170 (60.9) Spinal/Regional 69 (34.3%) 40 (51.3%) 109 (39.1) Application of Perianal Analgesics or Pudendal Anesthesics Yes 56 (27.9%) 30 (38.5%) 86 (30.8) No 145 (72.1%) 48 (61.5%) 193 (69.2) Outpatient Procedures Yes 67 (33.3) 13 (16.7) 80 (28.7) No 134 (66.7) 65 (83.3) 199 (71.3) (PROM: Patient reported outcome measure, HDSS: Hemorrhoidal Disease Severity Score, SHS-HD: Short Health Scale-Hemorrhoidal Disease) Decision-Making for Operative Technique: Excisional techniques (Milligan-Morgan [n = 142, 76.3%], Ferguson [n = 44, 23.6%]) were preferred in 186 (66.7%) patients, while non-excisional techniques (stapler hemorrhoidopexy: n = 3, 3.2%; HAL with/without mucopexy: n = 17, 18.3%; HeLP: n = 73, 78.5%) were favored in 93 (33.3%). Further analysis showed a trend towards a higher utilization of non-excisional techniques in males (p = 0.045) and a significant association between co-morbidities and the use of excisional techniques (p = 0.049) (Table 1 ). Patients who reported tenesmus (p = 0.019) or had a thrombosed hemorrhoid (p = 0.013) on physical examination were significantly more likely to be treated with excisional techniques. While Golligher score did not significantly influence surgical technique (p = 0.157), patients with higher HDSS (p = 0.01) and SHS-HD scores (p = 0.049) were more likely to undergo excisional procedures (Table 2 ). The choice of surgical technique varied significantly across the 9 different participating institutions (p < 0.001), and institutional type, whether governmental or private, was a significant determinant of the surgical approach employed (p < 0.001, Table 2 ). There were significant inter-hospital variations for both governmental and private institutions (p < 0.001 for both). Multivariate analysis demonstrated that the presence of thrombosed hemorrhoids and the hospital category significantly influenced the choice of surgical technique (both p = 0.001) (Table 3 and Fig. 1 -a). Table 3 Multivariate Logistic Regression Analysis of Variables Influencing the Decision-Making for Surgical Technique Variables B p-value (Sig.) Odds Ratio (Exp(B)) 95% Confidence Interval Gender (Male) -0.562 0.140 0.570 0.270–1.203 Age 0.008 0.572 1.008 0.981–1.036 Thrombus (Yes) 1.981 0.001 7.247 2.815–12.653 Tenesmus (Yes) 0.451 0.201 1.570 0.786–3.135 Comorbidity (ASA ≥ 3) 1.018 0.071 2.768 0.917–8.354 Preoperative HDSS -0.055 0.163 0.946 0.876–1.023 Preoperative SHS-HD 0.042 0.211 1.043 0.976–1.114 Hospital Category (Governmental) 1.622 0.001 5.065 2.656–9.656 Disease Grade (Grade 4) 0.649 0.061 1.914 0.970–3.778 ( Statistically significant p values were mentioned in bold .) Decision-Making for Other Perioperative Measures: Current study also investigated the factors influencing the selection of anesthesia type, the application of perianal anesthetics or pudendal block, and the decision for outpatient surgery. Patient characteristics influenced perioperative management decisions. Smoking status significantly influenced the choice of anesthesia type (p = 0.034), while both smoking status and patient age were associated with the decision to administer perianal analgesia or pudendal block (p = 0.27 and p < 0.001, respectively). Patients experiencing pain were significantly more likely to undergo surgery under spinal/regional anesthesia (p = 0.017), while those with thrombosed hemorrhoids were more frequently administered perianal or pudendal analgesia (p = 0.011). Patients with Grade IV hemorrhoids were more likely to require general anesthesia and less likely to be discharged as outpatients compared to those with Grade III disease. Preoperative HDSS and SHS-HD scores, institutional factors (hospital and hospital category), and the type of surgical procedure (excisional vs. non-excisional) were significant predictors of perioperative management decisions. Significant inter-institutional variations were observed across all outcome measures in both governmental and private institutions (p < 0.001 for all) (Table 2 ). Multivariate analysis revealed that hospital category (p < 0.001), disease severity (p = 0.001), and the surgical technique employed (p < 0.001) were significant predictors of anesthesia type. Hospital category (p < 0.001) and the presence of fecal incontinence (p = 0.04) were significantly associated with the use of perianal or pudendal analgesia. Finally, comorbidities (p = 0.007), hospital category (p = 0.011), disease severity (p = 0.023), and the surgical technique utilized (p = 0.001) significantly influenced the decision for outpatient hospitalization following hemorrhoidectomy (Table 4, and Figure 1-b, 1-c and 1-d). Table 4 Multivariate Logistic Regression Analysis of Variables Influencing Decision-Making for Perioperative Outcome Measures Variables B p-value (Sig.) Odds Ratio (Exp(B)) 95% Confidence Interval Type of Anaesthesia Comorbidity (ASA ≥ 3) -0.317 0.488 0.728 0.297–1.786 Smoking (Yes) -0.035 0.923 0.966 0.478–1.953 Pain (Yes) -0.704 0.067 0.495 0.233–1.049 Institution Category (Private) 2.199 0.000 9.012 4.087–19.870 Preoperative HDSS -0.019 0.642 0.981 0.904–1.064 Preoperative SHS_HD 0.021 0.553 1.022 0.952–1.097 Disease Grades (Grade 3) -1.180 0.001 3.33 1.577–6.666 Surgical Technique (Non-Excisional) 1.916 0.000 6.792 3.008–15.336 Application of Perianal Analgesics Injection or Pudendal Anesthesia Comorbidity (ASA ≥ 3) -0.294 0.643 0.745 0.215–2.586 Smoking (Yes) 0.218 0.569 1.243 0.587–2.631 Institution Category (Private) 3.299 0.000 27.078 11.704–62.647 Preoperative HDSS -0.030 0.523 0.970 0.884–1.065 Preoperative SHS-HD 0.031 0.449 1.032 0.951–1.119 Disease Grade (Grade 4) 0.643 0.118 1.902 0.849–4.261 Surgical Technique (Non-excisional) 0.566 0.170 1.762 0.784–3.956 Gender (Male) 0.264 0.577 1.303 0.514–3.301 Thrombus (Yes) 0.190 0.677 1.209 0.495–2.954 Incontinence (Yes) -1.635 0.040 0.195 0.041–0.930 Outpatient Hospitalization Comorbidity (No) 1.200 0.007 3.319 1.378–7.997 Institution Category (Private) 0.513 0.011 1.970 1.176–3.184 Preoperative HDSS 0.046 0.243 1.047 0.969–1.132 Preoperative SHS_HD 0.062 0.061 1.064 0.997–1.136 Disease Grade (Grade 3) -0.847 0.023 2.321 1.123–4.765 Surgical Technique (Non-excisional) 1.116 0.001 3.052 1.612–5.775 Gender (Male) 0.273 0.471 1.314 0.625–2.762 (Statistically significant p values were mentioned in bold ) DISCUSSION Each surgical modality for the management of Grade III and IV hemorrhoids, including excisional hemorrhoidectomy, stapled hemorrhoidopexy, DG-HAL, and ablative techniques, presents a unique set of advantages and limitations with respect to postoperative outcomes, including pain and recovery time ( 17 – 21 ). Despite advancements in surgical techniques and perioperative care, significant variability persists in the management of hemorrhoidal disease across different clinical settings. While evidence supports the feasibility of various perioperative practices, their real-world application in clinical setting remains uncertain. A multicenter, nationwide, prospective cohort study was initiated to primarily investigate the impact of different surgical techniques on patient-reported outcome measures in patients with hemorrhoidal disease. This current analysis utilizes data from this ongoing study to evaluate the factors that influenced surgical and perioperative management decisions for patients with Grade III or IV hemorrhoids. The primary objective of this study was to investigate the factors influencing the choice of surgical technique in patients undergoing hemorrhoidal surgery. Surgical techniques were classified into excisional and non-excisional categories to enable a comprehensive analysis of the factors impacting surgical choice. Univariate analysis revealed that female sex, the presence of comorbidities (ASA ≥ 3), tenesmus, thrombosed hemorrhoids, and higher preoperative HDSS and SHS-HD scores were significantly associated with an increased likelihood of undergoing excisional hemorrhoidectomy. Given that current guidelines recommend surgical excision as the preferred treatment for thrombosed hemorrhoids due to their superior efficacy compared to conservative management, it is not surprising that thrombosis emerged as a significant predictor of the choice of excisional techniques in our analysis ( 10 , 22 ). The management of symptomatic hemorrhoids necessitates an individualized approach. Our findings support the established role of conventional hemorrhoidectomy, considered the gold standard for more symptomatic grade 3 and 4 HD ( 23 ). For Grade 4 hemorrhoids, characterized by extensive prolapse and often complicated by thrombosis, excisional hemorrhoidectomy is frequently considered the most effective and reliable procedure by many surgeons. This surgical method not only addresses the physical tissue but also effectively alleviates the significant symptoms associated with Grade 4 hemorrhoids, such as persistent bleeding, prolapse, and pain, which often prove unresponsive to less invasive interventions ( 24 ). Patients with higher HDSS and SHS-HD scores, indicative of more severe disease, were more likely to undergo excisional hemorrhoidectomy in our cohort, aligning with the recognized clinical practice for managing patients with significant symptoms. However, subsequent multivariate analysis revealed that only the presence of thrombosed hemorrhoids among the studied symptoms and signs emerged as a significant predictor of the choice of excisional techniques. This finding aligns with previous studies that suggest thrombosis often necessitates a more aggressive or specific surgical approach due to its potential complications and its impact on clinical outcomes ( 10 – 14 ). Besides, our findings highlight substantial differences in surgical decision-making practices across various institutions and hospital category was identified as the most significant factor influencing the choice of surgical approach. This study investigates the factors influencing the selection of perioperative management variables, including anesthesia type, perianal/pudendal analgesia use, and the decision for outpatient discharge. Although our findings suggest an association between smoking status, age, pain and the choices of anesthesia and analgesia techniques, the underlying factors that may drive these clinical decisions are not entirely clear. Further research may be required to explore the determinants of these clinical decisions, including surgeon preference, institutional protocols, and other patient- or institution-related factors. Patients with Grade III hemorrhoids and those with less severe symptoms (lower HDSS and SHS-HD scores) were more likely to undergo surgery under general anesthesia and be discharged on the same day. Furthermore, the utilization of perianal/pudendal analgesia was less frequent in these patient groups. General anesthesia was more frequently employed in the current study, but the choice of anesthesia technique (general vs. spinal/regional) in patients undergoing excisional hemorrhoidectomy might have been influenced by various factors beyond the severity of the complaints, including anesthesiologist preferences or institutional protocols. In addition, the lower preference for outpatient procedures following excisional techniques is not unexpected and likely attributable to the higher incidence of postoperative pain associated with these procedures. The study demonstrated a marked heterogeneity in the choice of surgical techniques and perioperative applications across various healthcare institutions. The preference for excisional and non-excisional techniques was significantly influenced by the operating institution. Furthermore, significant inter-institutional variations were observed in the choice of anesthesia type, the use of pudendal or perianal analgesia, and the frequency of outpatient procedures. Although conventional hemorrhoidectomy is widely accepted as the gold standard for severe hemorrhoids, our study demonstrates that the choice of surgical technique is not solely determined by patient characteristics ( 23 ). Significant inter-institutional variations in surgical practices highlight the influence of institutional factors, such as protocols, resources, and surgeon preferences, on surgical decision-making. Despite all centers being tertiary care institutions with presumably similar levels of experience and resource, a significant inter-institutional variation in surgical techniques was observed, which supports the notion that institutional factors are more influential than individual surgeon preferences. While differences in reimbursement policies related to the insurance system in Türkiye between governmental and private institutions may have played a role. In addition, these results may also be questioned because access to advanced technologies and expertise may vary between private and governmental institutions, potentially influencing the observed treatment variations. So, we have further analyzed the hospitals in governmental and private categories separately, which revealed a significant difference between governmental and private hospital categories. Furthermore, inter-institutional variability in surgical technique was also observed within each category, indicating institutional type as the major factor influencing the selection of surgical technique. In addition, as the significant inter-institutional variation observed in the choice of surgical technique, the institution where the surgery was performed significantly influenced the choice of anesthesia, the application of perianal or epidural analgesia, and discharge disposition, which highlights the substantial influence of institutional factors on the overall perioperative management of HD, as well. The observations underlined the substantial influence of institutional factors on the overall care pathway and suggested that factors, such as protocols, resources, and prevailing philosophies, play a more dominant role in shaping surgical decision-making rather than disease and patient related factors. In our opinion, these findings are noteworthy, as they highlight previously undocumented inter-institutional variations in operative and perioperative management of HD. Further research is warranted to investigate the specific factors driving these observed differences. While the Goligher classification, primarily based on the degree of prolapse of internal hemorrhoids, has been traditionally considered a significant factor in treatment decision-making, our study unexpectedly found that the Goligher classification did not significantly influence the choice of surgical technique ( 6 , 25 ). A key limitation of the Goligher classification is its narrow focus on internal hemorrhoid prolapse, which may lead to an overemphasis on surgical intervention and may not adequately reflect the complex pathophysiology and dynamic evolution of HD. Recognizing the limitations of this classification, revisions and novel systems have been proposed considering patient symptomatology and the dynamics of the disease to improve the clinical relevance. ( 15 , 26 – 31 ) This study demonstrates a lack of correlation between the Goligher classification and the surgical technique employed, highlighting the limited clinical utility of this classification system in guiding surgical decision-making. By reflecting real-world clinical practice, current information highlights the limitations of current classification system and emphasizes the need for a new system that prioritizes patient-reported outcomes, correlates treatment outcomes, and guides more effective and personalized management of HD. A significant limitation of this study is the inherent heterogeneity across institutions. Since the study design did not explicitly focus on inter-institutional variations, the data collected may be insufficient to fully explain the observed differences in surgical techniques. Furthermore, the study design did not clearly address patient selection bias, as it is unclear whether all consecutive patients were included from each participating center.Another limitation of the study design is the lack of comprehensive assessment of factors that may influence surgical decision-making, including surgeon experience, eligibility of surgical devices, patient preferences, and socioeconomic status. These variables may have contributed to the observed variations in surgical technique and other perioperative measures. To fully understand the factors influencing surgical technique selection and to explore the rationale behind surgeons' decisions regarding perioperative applications, future studies should delve deeper into the decision-making process of individual surgeons such as training, experience, exposure to different techniques, and institutional protocols, patient characteristics, and available resources. This will provide valuable insights into the factors that influence surgical practice and potentially identify opportunities for standardization. As conclusion, despite advancements in surgical techniques and perioperative care, significant inter-institutional variations were observed in the management of grade III and IV HD. Multivariate analysis revealed that while patient and disease-related factors, with the exception of thrombosed HD, did not significantly influence the choice of surgical technique, hospital category emerged as a major determinant of surgical technique and all other aspects of perioperative management, suggesting that institutional factors play a crucial role in shaping clinical practice. Declarations Author Contributions: Substantial contributions to conception and design, or analysis and interpretation of data: MO, MK, Acquisition of data: MK, OA, HB, ST, AT, IS, OC, NS, NCA, CT, RK, AEY, TG, SM, FMH, AS, NB, SL, RK, OA, MK, SK, HFK, NCA, MO Drating the article or revising it critically for important intellectual content: M.O., M.K, Final approval of the version to be published: M.O. Competing interests The authors declare no competing interests. Conflict of interest The authors declare that they did not receive any financial and non-financial interest. Funding Declaration The authors declare that they did not receive any funding Ethical approval Istanbul Medipol University Research Committee granted the study and Institutional Ethics Committee approved the protocol (Protocol number: E-10840098-772.02-3634) in compliance with the Declaration of Helsinki. Human ethics and consent to participate declaration This study was conducted in accordance with the Declaration of Helsinki. All participants provided informed consent prior to their inclusion in the study. Participation was voluntary, and participants could withdraw at any time without repercussions. References Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215-220. Agarwal N, Singh K, Sheikh P, Mittal K, Mathai V, Kumar A. Executive Summary - The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016. Indian J Surg. 2017;79(1):58-61. Tournu G, Abramowitz L, Couffignal C, et al. Prevalence of anal symptoms in general practice: a prospective study. BMC Fam Pract. 2019;20(1):14. Abramowitz L, Benabderrahmane M, Pospait D, Philip J, Laouénan C. The prevalence of proctological symptoms amongst patients who see general practitioners in France. Eur J Gen Pract. 2014;20(4):301-306. Rørvik H, et al. Hemorrhoidal Disease Symptom Score and Short Health ScaleHD: New Tools to Evaluate Symptoms and Health-Related Quality of Life in Hemorrhoidal Disease. Dis Colon Rectum. 2019;62:333-342. Goligher JC. Surgery of the Anus, Rectum and Colon. 4th ed. London, United Kingdom: Ballière Tindall; 1980. Brillantino A, Renzi A, Talento P, Brusciano L, Marano L, Grillo M, et al. The Italian Unitary Society of Colo-Proctology (Societa Italiana Unitaria di Colonproctologia) guidelines for management of acute and chronic hemorrhoidal disease. Ann Coloproctol 2024;40(4):287-320. Coremans G, Denis MA, Dewint P, Duinslaegar M, Gijsen I, et al. Belgian consensus guideline on management of hemorrhoidal disease. Acta Gastroenterol Belg 2021;84(1):101-120. Gallo G, Martellucci J, Sturiale A, Clerico G, Nilitos G, Marinos F, et al. Consensus tatement of Italian Society of Colorectal Surgery (SICCR) management and treatment of hemorrhoidal disease. Techniques in Coloproctol 2020;24:145-164. Hawkins AT, Davis BR, Bhama AR, Fang SH, Dawes AJ, Feingold DL, Lightner AL, Paquette IM; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2024 May 1;67(5):614-623 Kim BG, Kang H. The effect of preemptive perianal ropivacaine and ropivacaine with dexmedetomidine on pain after hemorrhoidectomy: a prospective, randomized, doble-blind, placebo-controlled study. Indian J Surg 2014;76(1):49-55. Mallmann C, Langenbach MR, Florescu RV, Köhler A, Barkus J, Ritz JP, et al. Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial. Int J Colorect Dis 2023;38(1):62. Lin CY, Liu YC, Chen JP, Hsu PH, Chang SL. General anesthesia with local infiltration reduces urine retention rate and prolongs analgesic effect than spinal anesthesia for hemorrhoidectomy. Front Surg 2024;11:1288023. Roxas MF, Delima MG. Randomized controlled trial to determine the effectiveness of Nivatvongs technique versus conventional local anaesthetic infiltration for outpatient haemorrhoidectomy. Asian J Surg 2006;29(2):70-3. Nyström PO, Qvist N, Raahave D, Lindsey I, Mortensen N; Stapled or Open Pile Procedure (STOPP) trial study group. Randomized clinical trial of symptom control after stapled ano-pexy or diathermy excision for haemorrhoid prolapse. Br J Surg. 2010;97:167–176 Hjortswang H, Järnerot G, Curman B, et al. The Short Health Scale: a valid measure of subjective health in ulcerative colitis. Scand J Gastroenterol. 2006;41:1196-1203. Lakmal K, Basnayake O, Jayarajah U, Samarasekera D. Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review. World J Surg. 2021;45:1222-1236. https://doi:10.1007/s00268-020-05923-2. Wang J, Chang-Chien C, Chen J, Lai C, Tang R. The role of lasers in hemorrhoidectomy. Dis Colon Rectum. 1991;34:78-82. https://doi:10.1007/BF02050213. Wee IJY, Koo CH, Seow-En I, Ng YYR, Lin W, Tan EJK. Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis. Ann Coloproctol. 2023;39(1):3-10. https://doi:10.3393/ac.2022.00598.0085. Cemil A, Ugur K, Salih GM, Merve K, Guray DM, Emine BS. Comparison of Laser Hemorrhoidoplasty and Milligan-Morgan Hemorrhoidectomy Techniques in the Treatment of Grade 2 and 3 Hemorrhoidal Disease. Am Surg. 2024;90(4):662-671. https://doi:10.1177/00031348231207301. Karkalemis K, Chalkias PL, Kasouli A, Chatzaki E, Papanikolaou S, Dedemadi G. Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease. Langenbecks Arch Surg. 2021;406(7):2489-2495. Chan KK, Arthur JD. External haemorrhoidal thrombosis: evidence for current management. Tech Coloproctol. 2013;17:21–25.). De Schepper H, Coremans G, Denis MA, et al. Belgian consensus guideline on the management of hemorrhoidal disease. Acta Gastro-enterologica Belgica. 2021 Jan-Mar;84(1):101-120 Acheson AG, Ng OCT. Haemorrhoidal disease. In: Sagar PM, Hill AG, Knowles CH, et al, eds. Keighley and Williams' Surgery of the Anus, Rectum & Colon. 4th ed. Boca Raton, FL: CRC Press; 2019:195-219. Rubbini M, Ascanelli S. Classification and guidelines of hemorrhoidal disease: Present and future. World J Gastrointest Surg. 2019 Mar 27;11(3):117-121 Morgado PJ, Suárez JA, Gómez LG, Morgado PJ., Jr Histoclinical basis for a new classification of hemorrhoidal disease. Dis Colon Rectum. 1988;31:474–480. Gerjy R, Lindhoff-Larson A, Nyström PO. Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients. Colorectal Dis. 2008;10:694–700. Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist's view. World J Gastroenterol. 2015;21:9245–9252. Elbetti C, Giani I, Novelli E, Fucini C, Martellucci J. The single pile classification: a new tool for the classification of haemorrhoidal disease and the comparison of treatment results. Updates Surg. 2015;67:421–426. Rubbini M, Ascanelli S, Fabbian F. Hemorrhoidal disease: is it time for a new classification? Int J Colorectal Dis. 2018;33:831–833. Rørvik HD, Styr K, Ilum L, McKinstry GL, Dragesund T, Campos AH, Brandstrup B, Olaison G. Hemorrhoidal Disease Symptom Score and Short Health ScaleHD: New Tools to Evaluate Symptoms and Health-Related Quality of Life in Hemorrhoidal Disease. Dis Colon Rectum. 2019;62:333–342 Table 2 Table 2 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files STROBEStatement.docx table2.docx Cite Share Download PDF Status: Published Journal Publication published 15 Apr, 2026 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 07 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviews received at journal 19 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers invited by journal 19 Aug, 2025 Editor assigned by journal 30 Jun, 2025 Submission checks completed at journal 30 Jun, 2025 First submitted to journal 26 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6981998\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":505439494,\"identity\":\"51607ccd-b4ec-4722-ab1c-c487e3830bb5\",\"order_by\":0,\"name\":\"Metin Kement\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYJCCAwwMCRDWxwYwZUBAAzNcC2PjTLiWBPxaGGBamnmJ0aLb3n/wcAFDmpxue+/xx7Y77BIb2Ju3STD+uIdTi9mZwwyHZzDkGJudOZfYnHsmObGB51iZBENCMW4tN5IZDvMwVCRuu5Fj2JzbxpzYIJFjBtSC22Vm9x+DtdRvu//GsNmyrT6xQf4NAS03mEFachLMbvAYNjO2HQbawkNAy5lkg8M8BmmG287kGM7sPXPcuI0nrdgiIQ2PluMHH3/mqUiWNzt+xuDDzx3Vsv3shzfe+GCDWwsEIEc3G4ggpGEUjIJRMApGAX4AANWfVSE3NJVBAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Bahcesehir University School of Medicine\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Metin\",\"middleName\":\"\",\"lastName\":\"Kement\",\"suffix\":\"\"},{\"id\":505439495,\"identity\":\"f018b52c-39b8-46fa-b2ed-8a22c5e89938\",\"order_by\":1,\"name\":\"Orhan Ali̇moglu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Goztepe Suleyman Yalcin Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Orhan\",\"middleName\":\"\",\"lastName\":\"Ali̇moglu\",\"suffix\":\"\"},{\"id\":505439496,\"identity\":\"bba6bc27-b175-4e5b-bf13-8d8a57b69ec5\",\"order_by\":2,\"name\":\"Hakan Baysal\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Goztepe Suleyman Yalcin Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hakan\",\"middleName\":\"\",\"lastName\":\"Baysal\",\"suffix\":\"\"},{\"id\":505439497,\"identity\":\"25d9e513-952f-4180-8db2-5551e1513bc5\",\"order_by\":3,\"name\":\"Salih Tosun\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Goztepe Suleyman Yalcin Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Salih\",\"middleName\":\"\",\"lastName\":\"Tosun\",\"suffix\":\"\"},{\"id\":505439498,\"identity\":\"86bd33db-45a0-4766-be0e-36133d743d0c\",\"order_by\":4,\"name\":\"Atif Tekin\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Medipol University School of Medicine, Medipol Mega Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Atif\",\"middleName\":\"\",\"lastName\":\"Tekin\",\"suffix\":\"\"},{\"id\":505439499,\"identity\":\"35ccff83-44c2-4bb0-b7de-10fe3c1da19e\",\"order_by\":5,\"name\":\"Ilker Sucullu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sucullu General Surgery Clinic\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ilker\",\"middleName\":\"\",\"lastName\":\"Sucullu\",\"suffix\":\"\"},{\"id\":505439500,\"identity\":\"3b0e6a84-918d-4df9-a3a2-a80672f6fd8a\",\"order_by\":6,\"name\":\"Osman Ci̇vil\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Medipol University School of Medicine, Medipol Bahcelievler Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Osman\",\"middleName\":\"\",\"lastName\":\"Ci̇vil\",\"suffix\":\"\"},{\"id\":505439501,\"identity\":\"864b22d1-fbcf-45d2-88ea-b435bca0b17b\",\"order_by\":7,\"name\":\"Nevi̇n Sakoğlu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Medipol University School of Medicine, Medipol Bahcelievler Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Nevi̇n\",\"middleName\":\"\",\"lastName\":\"Sakoğlu\",\"suffix\":\"\"},{\"id\":505439502,\"identity\":\"a15b24e1-eec3-4fa1-b0ec-dc87fbbb6269\",\"order_by\":8,\"name\":\"Naci̇ye Çiğdem Arslan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Medipol University School of Medicine, Medipol Bahcelievler Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Naci̇ye\",\"middleName\":\"Çiğdem\",\"lastName\":\"Arslan\",\"suffix\":\"\"},{\"id\":505439503,\"identity\":\"6f26ed21-37bb-40ab-b67b-7a8a74fa8350\",\"order_by\":9,\"name\":\"Ci̇had Tatar\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Istanbul Training and Research Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ci̇had\",\"middleName\":\"\",\"lastName\":\"Tatar\",\"suffix\":\"\"},{\"id\":505439504,\"identity\":\"a165b430-50db-489b-bdc4-36cdee2e835a\",\"order_by\":10,\"name\":\"Rozan Kaya\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Istanbul Training and Research Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Rozan\",\"middleName\":\"\",\"lastName\":\"Kaya\",\"suffix\":\"\"},{\"id\":505439505,\"identity\":\"5dd62fab-c438-4f28-9121-a3cfda721ca7\",\"order_by\":11,\"name\":\"Ali̇ Emre Nayci\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Istanbul Training and Research Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ali̇\",\"middleName\":\"Emre\",\"lastName\":\"Nayci\",\"suffix\":\"\"},{\"id\":505439506,\"identity\":\"09aec727-7ff4-4e61-92b1-00fa49fa981e\",\"order_by\":12,\"name\":\"Taygun Gülşen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sultanbeyli State Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Taygun\",\"middleName\":\"\",\"lastName\":\"Gülşen\",\"suffix\":\"\"},{\"id\":505439507,\"identity\":\"a07088b7-6b92-4a61-89c8-90318aed00b3\",\"order_by\":13,\"name\":\"Serhat Meri̇c\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Bagcilar Training and Research Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Serhat\",\"middleName\":\"\",\"lastName\":\"Meri̇c\",\"suffix\":\"\"},{\"id\":505439508,\"identity\":\"980bd07a-53a5-41f3-960e-4db54f8d3ebc\",\"order_by\":14,\"name\":\"Farid Mohamad Hamad\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Bagcilar Training and Research Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Farid\",\"middleName\":\"Mohamad\",\"lastName\":\"Hamad\",\"suffix\":\"\"},{\"id\":505439509,\"identity\":\"8eecef17-63af-4ac4-a567-6aec9d1e66ed\",\"order_by\":15,\"name\":\"Ahmed Salhat\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Bagcilar Training and Research Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ahmed\",\"middleName\":\"\",\"lastName\":\"Salhat\",\"suffix\":\"\"},{\"id\":505439510,\"identity\":\"f4961811-40ed-47b2-af01-443f9c20430f\",\"order_by\":16,\"name\":\"Ni̇hat Buğdayci\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Health Sciences, Bagcilar Training and Research Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ni̇hat\",\"middleName\":\"\",\"lastName\":\"Buğdayci\",\"suffix\":\"\"},{\"id\":505439511,\"identity\":\"66459e70-c4a0-4316-8e9f-72c2d61a1245\",\"order_by\":17,\"name\":\"Sezai̇ Leventoğu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gazi University School of Medicine\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sezai̇\",\"middleName\":\"\",\"lastName\":\"Leventoğu\",\"suffix\":\"\"},{\"id\":505439512,\"identity\":\"9773a0ee-f572-4264-a213-ec1f38300c6a\",\"order_by\":18,\"name\":\"Ramazan Kozan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gazi University School of Medicine\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ramazan\",\"middleName\":\"\",\"lastName\":\"Kozan\",\"suffix\":\"\"},{\"id\":505439513,\"identity\":\"cb8d4e6a-faae-4db0-b493-949154c6d9bb\",\"order_by\":19,\"name\":\"Özkan Akpinar\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Gazi University School of Medicine\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Özkan\",\"middleName\":\"\",\"lastName\":\"Akpinar\",\"suffix\":\"\"},{\"id\":505439514,\"identity\":\"1b408644-2430-4314-98c3-b687eeda4074\",\"order_by\":20,\"name\":\"Mehmet Karahan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Kartal City Hospital, Health Sciences University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mehmet\",\"middleName\":\"\",\"lastName\":\"Karahan\",\"suffix\":\"\"},{\"id\":505439515,\"identity\":\"1b843870-016f-4555-8774-a0c2fdadb553\",\"order_by\":21,\"name\":\"Selçuk Kaya\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Kartal City Hospital, Health Sciences University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Selçuk\",\"middleName\":\"\",\"lastName\":\"Kaya\",\"suffix\":\"\"},{\"id\":505439516,\"identity\":\"5741bcb1-b7bd-44e7-a818-a03b853b1031\",\"order_by\":22,\"name\":\"Hasan Fehmi̇ Küçük\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Kartal City Hospital, Health Sciences University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hasan\",\"middleName\":\"Fehmi̇\",\"lastName\":\"Küçük\",\"suffix\":\"\"},{\"id\":505439518,\"identity\":\"2c3e07ab-c637-46ba-a43f-79f74fc49584\",\"order_by\":23,\"name\":\"Nail Can Adigüzel\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Kartal City Hospital, Health Sciences University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Nail\",\"middleName\":\"Can\",\"lastName\":\"Adigüzel\",\"suffix\":\"\"},{\"id\":505439520,\"identity\":\"34445275-9def-4869-a1ca-50e432550ebf\",\"order_by\":24,\"name\":\"Mustafa Oncel\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Medipol University School of Medicine, Medipol Mega Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mustafa\",\"middleName\":\"\",\"lastName\":\"Oncel\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-06-26 09:38:34\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6981998/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6981998/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1007/s00423-026-04030-5\",\"type\":\"published\",\"date\":\"2026-04-15T15:58:53+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":90012376,\"identity\":\"de02125d-21d1-4da6-ba98-2d1386dc42b8\",\"added_by\":\"auto\",\"created_at\":\"2025-08-27 11:02:00\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":496586,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSee image above for figure legend\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6981998/v1/45cb2520470f70dd05633c6c.png\"},{\"id\":107351944,\"identity\":\"f894d176-8996-43e4-ab57-700878e40308\",\"added_by\":\"auto\",\"created_at\":\"2026-04-20 16:12:52\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1505260,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6981998/v1/ae4ccf16-a8ec-41ad-a0a0-913e7e16000c.pdf\"},{\"id\":90013193,\"identity\":\"3f776ee6-1370-4dab-b612-210583f3fa89\",\"added_by\":\"auto\",\"created_at\":\"2025-08-27 11:10:01\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":29424,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"STROBEStatement.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6981998/v1/3048bdd596bd0d5721c6cd02.docx\"},{\"id\":90012369,\"identity\":\"08595ecc-f570-49be-8914-f88ba1154de7\",\"added_by\":\"auto\",\"created_at\":\"2025-08-27 11:02:00\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":42113,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"table2.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6981998/v1/edd61b4104cf5f139cba572b.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Determinants Influencing Decision-Making for Operative and Perioperative Management of Grade III and IV Hemorrhoidal Disease: Secondary Analysis of a Multicenter Nationwide Prospective Cohort Study\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eHemorrhoidal disease (HD) is a common anorectal condition with a significant impact on patient quality of life. Despite its prevalence, the management of HD exhibits considerable variability in clinical practice, influenced by diverse therapeutic approaches, regional healthcare systems, and evolving treatment technologies (\\u003cspan additionalcitationids=\\\"CR2 CR3 CR4\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). The Goligher classification, a four-grade system for categorizing the severity of hemorrhoidal prolapse, is widely recognized as a crucial determinant in treatment decision-making, particularly in the selection of surgical technique (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eCurrent clinical guidelines recommend a range of surgical approaches for the management of Grade III and IV hemorrhoids, including excisional hemorrhoidectomy, stapled hemorrhoidopexy, doppler-guided hemorrhoidal artery ligation, and ablative techniques (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). The management of symptomatic hemorrhoids necessitates an individualized approach. Our findings support the established role of conventional hemorrhoidectomy, considered the gold standard for more symptomatic grade 3 and 4 hemorrhoids. Patients with higher HDSS and SHS-HD scores, indicative of more severe disease, were more likely to undergo excisional hemorrhoidectomy in our cohort, aligning with the recognized clinical practice for managing patients with significant symptoms (\\u003cspan additionalcitationids=\\\"CR9\\\" citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Each surgical modality presents distinct advantages and limitations with respect to postoperative pain, quality of life, recovery time, and cost (\\u003cspan additionalcitationids=\\\"CR9\\\" citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Despite advancements in surgical techniques, considerable variability exists in the perioperative management of HD across clinical settings. Prospective randomized trials have consistently demonstrated the superiority of several anesthetic approaches, including general anesthesia with local infiltration, over spinal anesthesia alone. Other applications include the use of adjunctive analgesia such as pudendal nerve block or perianal injections of local anesthetics for improved postoperative pain control (\\u003cspan additionalcitationids=\\\"CR12\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Advancements in surgical techniques, such as minimally invasive procedures and enhanced postoperative pain management, have made outpatient hemorrhoidectomy a feasible and increasingly common option (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). Despite the evidence supporting these practices, there is a significant gap in our understanding of their real-world application. This variability in clinical practice may be influenced by a multitude of factors, including institutional policies, surgeon expertise, patient preferences, and the characteristics of the healthcare system. However, the specific factors that drive clinician decision-making in the selection of these different management approaches remain largely unexplored. The significant variability in the management of HD across different settings highlights the crucial importance of conducting multicenter analyses to identify patterns, discrepancies, and ultimately establish best practices in the field. Utilizing data from a multicenter nationwide prospective cohort study, this study aims to investigate the factors that influenced surgical decision-making in the treatment of HD, including the choice of surgical techniques and the implementation of various perioperative applications.\\u003c/p\\u003e\"},{\"header\":\"METHODS\",\"content\":\"\\u003cp\\u003e A prospective cohort study was conducted between July 2022 and July 2024 at 20 tertiary care or university hospitals across diverse regions at T\\u0026uuml;rkiye (registered on ClinicalTrials.gov with the identifier number of NCT05429060). Istanbul Medipol University Research Committee granted the study and Institutional Ethics Committee approved the protocol (Protocol number: E-10840098-772.02-3634) in compliance with the Declaration of Helsinki. This study presents a secondary analysis of abstracted information to identify the factors influencing surgeons' preferences for surgical approaches. To ensure data homogeneity, we included only patients with grade 2 or 3 disease and centers that contributed at least 10 cases to the study.\\u003c/p\\u003e\\u003cp\\u003ePatients aged 18 years and older who underwent surgery for symptomatic hemorrhoidal disease were included. Exclusion criteria included patients with concurrent proctological conditions such as fistulas, abscesses, and fissures; a history of prior hemorrhoid surgery; inflammatory bowel disease; pelvic or perineal radiation; previous perianal trauma or obstetric injury; and prior rectal surgeries for benign or malignant conditions. To ensure standardized treatment, all patients were required to undergo at least four weeks of conservative management prior to surgical intervention. Sigmoidoscopy was required for patients under 50, while colonoscopy was mandatory for those over 50 to rule out other potential pathologies. All perioperative process including surgical technique, anesthesia type, application of pudendal or perianal analgesic application and outpatient hospitalization was decided by the surgical teams or surgeons.\\u003c/p\\u003e\\u003cp\\u003eData collection included patient demographics, body mass index, anticoagulant use, comorbidities (American Society of Anesthesiology (ASA) Score), smoking, and delivery history. Surgical teams also recorded patient complaints (pain, itching, bleeding, prolapse, soiling, tenesmus, constipation, and incontinence), physical examination findings (prolapse, skin tags, thrombus, bleeding, soiling/discharge), and disease severity using the Golligher classification (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). Two different questionnaires were used for reporting patient reported outcome measures (PROMs). The severity of hemorrhoidal symptoms was assessed using the Hemorrhoidal Disease Symptom Score (HDSS), a 5-item scale with a possible range from 0 to 20 (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). Health-related quality of life associated with hemorrhoids was evaluated using the Short Health Scale-Hemorrhoidal Disease (SHS-HD), a 4-item scale with a possible range from 0 to 21 (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). The experience level of the operating surgeon, whether attending staff or supervised resident, was recorded.\\u003c/p\\u003e\\u003cp\\u003eAccording to study protocol, perioperative management decisions, including surgical technique, anesthesia type, application of pudental analgesia or perianal analgesics, and time for discharge were left to the discretion of the surgical teams. Surgical techniques were categorized as excisional (Milligan-Morgan and Ferguson hemorrhoidectomy) or non-excisional (stapler hemorrhoidopexy, Doppler-guided hemorrhoidal artery ligation [HAL] with or without mucopexy, and laser [HeLP]). Other perioperative measures including anesthesia type (general, spinal/regional), the application of perianal anesthetics or pudendal block, and outpatient status following surgery were documented. The participating hospital where the surgery was performed, as well as hospital category (governmental or private), was recorded.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStatistics\\u003c/h2\\u003e\\u003cp\\u003eAll analyses were performed using SPSS version 26. Continuous variables were presented as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation, and categorical variables as frequencies and percentages.Group comparisons were conducted using one-way ANOVA for normally distributed data and the Kruskal-Wallis test for non-normally distributed data. Categorical variables were analyzed using chi-square or Fisher\\u0026rsquo;s exact tests, with adjusted residuals explored for significant associations.Binary logistic regression was used to identify factors influencing surgical and perioperative decisions. Variables with a univariate p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.2 were included in multivariate models. A p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 threshold was considered statistically significant. Multicollinearity was evaluated using.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003e Out of the 315 patients operated on across 20 participating centers, only 279 patients (88.6%) from 9 institutions were eligible for inclusion in the study. The mean age of patients was 43.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;11.4 years with male majority (n\\u0026thinsp;=\\u0026thinsp;214, 76.7%). All included centers were tertiary-level governmental (n\\u0026thinsp;=\\u0026thinsp;6) or private (n\\u0026thinsp;=\\u0026thinsp;3) institutions affiliated to universities or education and research hospitals, providing a consistent standard of care and resource availability. Grade III hemorrhoids were observed in 201 (72%) patients, and Grade IV in 78 (28%). Surgical procedures were performed in 170 (60.9%) patients at governmental hospitals and 109 (39.1%) at private institutions. Demographic and perioperative data for the cohort, encompassing both grade III and grade IV disease, are summarized in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003ePatient Characteristics and Perioperative Data for the Cohort\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eStudied Parameters\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eGrade III (n\\u0026thinsp;=\\u0026thinsp;201)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eGrade IV (n\\u0026thinsp;=\\u0026thinsp;78)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eStudy Cohort (n\\u0026thinsp;=\\u0026thinsp;279)\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003ePatient Characteristics\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGender (male, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e152(75.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e62 (79.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e214 (76.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAge (mean years \\u0026plusmn;SD)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e44.3\\u0026plusmn;11.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e42\\u0026plusmn;11.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e43.6\\u0026plusmn;11.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBMI (mean kg/m2 \\u0026plusmn;SD)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e26.1\\u0026plusmn;3.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e25.2\\u0026plusmn;3.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e25.9\\u0026plusmn;3.6\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eComorbidity (ASA\\u0026thinsp;\\u0026ge;\\u0026thinsp;3) (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e23 (11.4%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10 (12.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e33 (11.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAnti-coagulant (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e11 (3.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSmoking (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e61 (30.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e26 (33.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e87 (31.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDelivery History n\\u0026thinsp;=\\u0026thinsp;65 F (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25(51 of F)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10(62.5 of F)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e35 (52.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003ePatient Complaints\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePain (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e148 (73.6%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e58 (74.4%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e206 (73.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eItching (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e94 (46.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e33 (42.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e127 (45.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBleeding (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e137 (68.2%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e57 (73.1%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e194 (69.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eProlapse (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e82 (40.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e56 (71.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e138 (49.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSoiling (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e73 (36.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e36 (46.2%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e109 (39.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTenesmus (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e55 (27.4%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e24 (30.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e79 (28.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eConstipation (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e99 (49.5%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e38 (48.7%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e137 (49.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eIncontinence (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e13 (6.5%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10 (12.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e23 (8.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003ePhysical Examination Findings\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eProlapse (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e68 (33.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e53 (67.9%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e121 (43.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSkin Tag (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e61 (30.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e26 (33.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e87 831.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eThrombus (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e34 (16.9%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e19 (24.4%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e53 (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBleeding (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e84 (41.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e41 (52.6%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e125 (44.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSoiling/Discharge (n, %)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e62 (31.0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e29 (37.2%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e91 (32.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003ePROMs\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePreop. SHS-HD(mean\\u0026plusmn;SD)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e16.5\\u0026plusmn;5.3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e18.1\\u0026plusmn;5.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e16.9\\u0026plusmn;5.2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePreop. HDSS (mean\\u0026plusmn;SD)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e10.5\\u0026plusmn;4.7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10.7\\u0026plusmn;4.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e10.6\\u0026plusmn;4.5\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eHosiptals\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGovernmental Institutions\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e26 (12.9%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e6 (7.7%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e32 (11.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8 (4.0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e2 (2.6%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e10 (3.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e65 (32.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e8 (10.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e73 (26.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e19 (9.5%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10 (12.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e29 (10.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#6\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e10 (5.0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e6 (7.7%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e16 (5.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0 (0.0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10 (12.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e10 (3.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePrivate Institutions\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e14 (7.0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e9 (11.5%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e23 (8.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e53 (26.4%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e20 (25.6%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e73 (26.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e#8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6 (3.0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e7 (9.0%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e13 (4.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eHospital Category\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGovernment\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e128 (63.7%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e42 (53.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e170 (60.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePrivate\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e73 (36.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e36 (46.2%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e109 (39.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eSurgical Technique\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eExcisional\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e129 (64.2%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e57 (73.1%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e186 (66.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eNon-Excisional\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e72 (35.8%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e21 (26.9%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e93 (33.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eAnesthesia Type\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGeneral\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e132 (65.7%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e38 (48.7%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e170 (60.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSpinal/Regional\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e69 (34.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e40 (51.3%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e109 (39.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eApplication of Perianal Analgesics or Pudendal Anesthesics\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eYes\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e56 (27.9%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e30 (38.5%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e86 (30.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eNo\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e145 (72.1%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e48 (61.5%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e193 (69.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eOutpatient Procedures\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eYes\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e67 (33.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e13 (16.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e80 (28.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eNo\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e134 (66.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e65 (83.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e199 (71.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e(PROM: Patient reported outcome measure, HDSS: Hemorrhoidal Disease Severity Score, SHS-HD: Short Health Scale-Hemorrhoidal Disease)\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eDecision-Making for Operative Technique:\\u003c/h3\\u003e\\n\\u003cp\\u003eExcisional techniques (Milligan-Morgan [n\\u0026thinsp;=\\u0026thinsp;142, 76.3%], Ferguson [n\\u0026thinsp;=\\u0026thinsp;44, 23.6%]) were preferred in 186 (66.7%) patients, while non-excisional techniques (stapler hemorrhoidopexy: n\\u0026thinsp;=\\u0026thinsp;3, 3.2%; HAL with/without mucopexy: n\\u0026thinsp;=\\u0026thinsp;17, 18.3%; HeLP: n\\u0026thinsp;=\\u0026thinsp;73, 78.5%) were favored in 93 (33.3%). Further analysis showed a trend towards a higher utilization of non-excisional techniques in males (p\\u0026thinsp;=\\u0026thinsp;0.045) and a significant association between co-morbidities and the use of excisional techniques (p\\u0026thinsp;=\\u0026thinsp;0.049) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Patients who reported tenesmus (p\\u0026thinsp;=\\u0026thinsp;0.019) or had a thrombosed hemorrhoid (p\\u0026thinsp;=\\u0026thinsp;0.013) on physical examination were significantly more likely to be treated with excisional techniques. While Golligher score did not significantly influence surgical technique (p\\u0026thinsp;=\\u0026thinsp;0.157), patients with higher HDSS (p\\u0026thinsp;=\\u0026thinsp;0.01) and SHS-HD scores (p\\u0026thinsp;=\\u0026thinsp;0.049) were more likely to undergo excisional procedures (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). The choice of surgical technique varied significantly across the 9 different participating institutions (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), and institutional type, whether governmental or private, was a significant determinant of the surgical approach employed (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001, Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). There were significant inter-hospital variations for both governmental and private institutions (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001 for both). Multivariate analysis demonstrated that the presence of thrombosed hemorrhoids and the hospital category significantly influenced the choice of surgical technique (both p\\u0026thinsp;=\\u0026thinsp;0.001) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e and Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e-a).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eMultivariate Logistic Regression Analysis of Variables Influencing the Decision-Making for Surgical Technique\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eVariables\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eB\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ep-value (Sig.)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOdds Ratio (Exp(B))\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e95% Confidence Interval\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGender (Male)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.562\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.140\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.570\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.270\\u0026ndash;1.203\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAge\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.008\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.572\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.008\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.981\\u0026ndash;1.036\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eThrombus (Yes)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.981\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e7.247\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.815\\u0026ndash;12.653\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTenesmus (Yes)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.451\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.201\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.570\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.786\\u0026ndash;3.135\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eComorbidity (ASA\\u0026thinsp;\\u0026ge;\\u0026thinsp;3)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.018\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.071\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.768\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.917\\u0026ndash;8.354\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative HDSS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.055\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.163\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.946\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.876\\u0026ndash;1.023\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative SHS-HD\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.042\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.211\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.043\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.976\\u0026ndash;1.114\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHospital Category (Governmental)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.622\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.065\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.656\\u0026ndash;9.656\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDisease Grade (Grade 4)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.649\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.061\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.914\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.970\\u0026ndash;3.778\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003cstrong\\u003e(\\u003c/strong\\u003eStatistically significant p values were mentioned in \\u003cstrong\\u003ebold\\u003c/strong\\u003e.)\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDecision-Making for Other Perioperative Measures:\\u003c/p\\u003e\\n\\u003cp\\u003eCurrent study also investigated the factors influencing the selection of anesthesia type, the application of perianal anesthetics or pudendal block, and the decision for outpatient surgery. Patient characteristics influenced perioperative management decisions. Smoking status significantly influenced the choice of anesthesia type (p\\u0026thinsp;=\\u0026thinsp;0.034), while both smoking status and patient age were associated with the decision to administer perianal analgesia or pudendal block (p\\u0026thinsp;=\\u0026thinsp;0.27 and p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001, respectively). Patients experiencing pain were significantly more likely to undergo surgery under spinal/regional anesthesia (p\\u0026thinsp;=\\u0026thinsp;0.017), while those with thrombosed hemorrhoids were more frequently administered perianal or pudendal analgesia (p\\u0026thinsp;=\\u0026thinsp;0.011). Patients with Grade IV hemorrhoids were more likely to require general anesthesia and less likely to be discharged as outpatients compared to those with Grade III disease. Preoperative HDSS and SHS-HD scores, institutional factors (hospital and hospital category), and the type of surgical procedure (excisional vs. non-excisional) were significant predictors of perioperative management decisions. Significant inter-institutional variations were observed across all outcome measures in both governmental and private institutions (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001 for all) (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eMultivariate analysis revealed that hospital category (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), disease severity (p\\u0026thinsp;=\\u0026thinsp;0.001), and the surgical technique employed (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) were significant predictors of anesthesia type. Hospital category (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and the presence of fecal incontinence (p\\u0026thinsp;=\\u0026thinsp;0.04) were significantly associated with the use of perianal or pudendal analgesia. Finally, comorbidities (p\\u0026thinsp;=\\u0026thinsp;0.007), hospital category (p\\u0026thinsp;=\\u0026thinsp;0.011), disease severity (p\\u0026thinsp;=\\u0026thinsp;0.023), and the surgical technique utilized (p\\u0026thinsp;=\\u0026thinsp;0.001) significantly influenced the decision for outpatient hospitalization following hemorrhoidectomy (Table 4, and Figure 1-b, 1-c and 1-d).\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab4\\\" border=\\\"1\\\" class=\\\"fr-table-selection-hover\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eMultivariate Logistic Regression Analysis of Variables Influencing Decision-Making for Perioperative Outcome Measures\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eVariables\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eB\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ep-value (Sig.)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOdds Ratio (Exp(B))\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e95% Confidence Interval\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eType of Anaesthesia\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eComorbidity (ASA\\u0026thinsp;\\u0026ge;\\u0026thinsp;3)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.317\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.488\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.728\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.297\\u0026ndash;1.786\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSmoking (Yes)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.035\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.923\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.966\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.478\\u0026ndash;1.953\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePain (Yes)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.704\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.067\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.495\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.233\\u0026ndash;1.049\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eInstitution Category (Private)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.199\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.000\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e9.012\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e4.087\\u0026ndash;19.870\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative HDSS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.019\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.642\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.981\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.904\\u0026ndash;1.064\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative SHS_HD\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.021\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.553\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.022\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.952\\u0026ndash;1.097\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDisease Grades (Grade 3)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-1.180\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.33\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.577\\u0026ndash;6.666\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSurgical Technique (Non-Excisional)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.916\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.000\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6.792\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.008\\u0026ndash;15.336\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eApplication of Perianal Analgesics Injection or Pudendal Anesthesia\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eComorbidity (ASA\\u0026thinsp;\\u0026ge;\\u0026thinsp;3)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.294\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.643\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.745\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.215\\u0026ndash;2.586\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSmoking (Yes)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.218\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.569\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.243\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.587\\u0026ndash;2.631\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eInstitution Category (Private)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.299\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.000\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27.078\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e11.704\\u0026ndash;62.647\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative HDSS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.030\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.523\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.970\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.884\\u0026ndash;1.065\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative SHS-HD\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.031\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.449\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.032\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.951\\u0026ndash;1.119\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDisease Grade (Grade 4)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.643\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.118\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.902\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.849\\u0026ndash;4.261\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSurgical Technique (Non-excisional)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.566\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.170\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.762\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.784\\u0026ndash;3.956\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGender (Male)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.264\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.577\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.303\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.514\\u0026ndash;3.301\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eThrombus (Yes)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.190\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.677\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.209\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.495\\u0026ndash;2.954\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eIncontinence (Yes)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-1.635\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.040\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.195\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.041\\u0026ndash;0.930\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOutpatient Hospitalization\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eComorbidity (No)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.200\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.007\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.319\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.378\\u0026ndash;7.997\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eInstitution Category (Private)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.513\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.011\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.970\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.176\\u0026ndash;3.184\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative HDSS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.046\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.243\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.047\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.969\\u0026ndash;1.132\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative SHS_HD\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.062\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.061\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.064\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.997\\u0026ndash;1.136\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDisease Grade (Grade 3)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.847\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.023\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.321\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.123\\u0026ndash;4.765\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSurgical Technique (Non-excisional)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.116\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.052\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.612\\u0026ndash;5.775\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGender (Male)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.273\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.471\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.314\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.625\\u0026ndash;2.762\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e(Statistically significant p values were mentioned in \\u003cstrong\\u003ebold\\u003c/strong\\u003e)\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n\\u003c/table\\u003e\\n\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eEach surgical modality for the management of Grade III and IV hemorrhoids, including excisional hemorrhoidectomy, stapled hemorrhoidopexy, DG-HAL, and ablative techniques, presents a unique set of advantages and limitations with respect to postoperative outcomes, including pain and recovery time (\\u003cspan additionalcitationids=\\\"CR18 CR19 CR20\\\" citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e). Despite advancements in surgical techniques and perioperative care, significant variability persists in the management of hemorrhoidal disease across different clinical settings. While evidence supports the feasibility of various perioperative practices, their real-world application in clinical setting remains uncertain. A multicenter, nationwide, prospective cohort study was initiated to primarily investigate the impact of different surgical techniques on patient-reported outcome measures in patients with hemorrhoidal disease. This current analysis utilizes data from this ongoing study to evaluate the factors that influenced surgical and perioperative management decisions for patients with Grade III or IV hemorrhoids.\\u003c/p\\u003e\\u003cp\\u003eThe primary objective of this study was to investigate the factors influencing the choice of surgical technique in patients undergoing hemorrhoidal surgery. Surgical techniques were classified into excisional and non-excisional categories to enable a comprehensive analysis of the factors impacting surgical choice. Univariate analysis revealed that female sex, the presence of comorbidities (ASA\\u0026thinsp;\\u0026ge;\\u0026thinsp;3), tenesmus, thrombosed hemorrhoids, and higher preoperative HDSS and SHS-HD scores were significantly associated with an increased likelihood of undergoing excisional hemorrhoidectomy. Given that current guidelines recommend surgical excision as the preferred treatment for thrombosed hemorrhoids due to their superior efficacy compared to conservative management, it is not surprising that thrombosis emerged as a significant predictor of the choice of excisional techniques in our analysis (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). The management of symptomatic hemorrhoids necessitates an individualized approach. Our findings support the established role of conventional hemorrhoidectomy, considered the gold standard for more symptomatic grade 3 and 4 HD (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e). For Grade 4 hemorrhoids, characterized by extensive prolapse and often complicated by thrombosis, excisional hemorrhoidectomy is frequently considered the most effective and reliable procedure by many surgeons. This surgical method not only addresses the physical tissue but also effectively alleviates the significant symptoms associated with Grade 4 hemorrhoids, such as persistent bleeding, prolapse, and pain, which often prove unresponsive to less invasive interventions (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). Patients with higher HDSS and SHS-HD scores, indicative of more severe disease, were more likely to undergo excisional hemorrhoidectomy in our cohort, aligning with the recognized clinical practice for managing patients with significant symptoms. However, subsequent multivariate analysis revealed that only the presence of thrombosed hemorrhoids among the studied symptoms and signs emerged as a significant predictor of the choice of excisional techniques. This finding aligns with previous studies that suggest thrombosis often necessitates a more aggressive or specific surgical approach due to its potential complications and its impact on clinical outcomes (\\u003cspan additionalcitationids=\\\"CR11 CR12 CR13\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). Besides, our findings highlight substantial differences in surgical decision-making practices across various institutions and hospital category was identified as the most significant factor influencing the choice of surgical approach.\\u003c/p\\u003e\\u003cp\\u003eThis study investigates the factors influencing the selection of perioperative management variables, including anesthesia type, perianal/pudendal analgesia use, and the decision for outpatient discharge. Although our findings suggest an association between smoking status, age, pain and the choices of anesthesia and analgesia techniques, the underlying factors that may drive these clinical decisions are not entirely clear. Further research may be required to explore the determinants of these clinical decisions, including surgeon preference, institutional protocols, and other patient- or institution-related factors. Patients with Grade III hemorrhoids and those with less severe symptoms (lower HDSS and SHS-HD scores) were more likely to undergo surgery under general anesthesia and be discharged on the same day. Furthermore, the utilization of perianal/pudendal analgesia was less frequent in these patient groups. General anesthesia was more frequently employed in the current study, but the choice of anesthesia technique (general vs. spinal/regional) in patients undergoing excisional hemorrhoidectomy might have been influenced by various factors beyond the severity of the complaints, including anesthesiologist preferences or institutional protocols. In addition, the lower preference for outpatient procedures following excisional techniques is not unexpected and likely attributable to the higher incidence of postoperative pain associated with these procedures.\\u003c/p\\u003e\\u003cp\\u003eThe study demonstrated a marked heterogeneity in the choice of surgical techniques and perioperative applications across various healthcare institutions. The preference for excisional and non-excisional techniques was significantly influenced by the operating institution. Furthermore, significant inter-institutional variations were observed in the choice of anesthesia type, the use of pudendal or perianal analgesia, and the frequency of outpatient procedures. Although conventional hemorrhoidectomy is widely accepted as the gold standard for severe hemorrhoids, our study demonstrates that the choice of surgical technique is not solely determined by patient characteristics (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e). Significant inter-institutional variations in surgical practices highlight the influence of institutional factors, such as protocols, resources, and surgeon preferences, on surgical decision-making. Despite all centers being tertiary care institutions with presumably similar levels of experience and resource, a significant inter-institutional variation in surgical techniques was observed, which supports the notion that institutional factors are more influential than individual surgeon preferences. While differences in reimbursement policies related to the insurance system in T\\u0026uuml;rkiye between governmental and private institutions may have played a role. In addition, these results may also be questioned because access to advanced technologies and expertise may vary between private and governmental institutions, potentially influencing the observed treatment variations. So, we have further analyzed the hospitals in governmental and private categories separately, which revealed a significant difference between governmental and private hospital categories. Furthermore, inter-institutional variability in surgical technique was also observed within each category, indicating institutional type as the major factor influencing the selection of surgical technique. In addition, as the significant inter-institutional variation observed in the choice of surgical technique, the institution where the surgery was performed significantly influenced the choice of anesthesia, the application of perianal or epidural analgesia, and discharge disposition, which highlights the substantial influence of institutional factors on the overall perioperative management of HD, as well. The observations underlined the substantial influence of institutional factors on the overall care pathway and suggested that factors, such as protocols, resources, and prevailing philosophies, play a more dominant role in shaping surgical decision-making rather than disease and patient related factors. In our opinion, these findings are noteworthy, as they highlight previously undocumented inter-institutional variations in operative and perioperative management of HD. Further research is warranted to investigate the specific factors driving these observed differences.\\u003c/p\\u003e\\u003cp\\u003eWhile the Goligher classification, primarily based on the degree of prolapse of internal hemorrhoids, has been traditionally considered a significant factor in treatment decision-making, our study unexpectedly found that the Goligher classification did not significantly influence the choice of surgical technique (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). A key limitation of the Goligher classification is its narrow focus on internal hemorrhoid prolapse, which may lead to an overemphasis on surgical intervention and may not adequately reflect the complex pathophysiology and dynamic evolution of HD. Recognizing the limitations of this classification, revisions and novel systems have been proposed considering patient symptomatology and the dynamics of the disease to improve the clinical relevance. (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR27 CR28 CR29 CR30\\\" citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e) This study demonstrates a lack of correlation between the Goligher classification and the surgical technique employed, highlighting the limited clinical utility of this classification system in guiding surgical decision-making. By reflecting real-world clinical practice, current information highlights the limitations of current classification system and emphasizes the need for a new system that prioritizes patient-reported outcomes, correlates treatment outcomes, and guides more effective and personalized management of HD.\\u003c/p\\u003e\\u003cp\\u003eA significant limitation of this study is the inherent heterogeneity across institutions. Since the study design did not explicitly focus on inter-institutional variations, the data collected may be insufficient to fully explain the observed differences in surgical techniques. Furthermore, the study design did not clearly address patient selection bias, as it is unclear whether all consecutive patients were included from each participating center.Another limitation of the study design is the lack of comprehensive assessment of factors that may influence surgical decision-making, including surgeon experience, eligibility of surgical devices, patient preferences, and socioeconomic status. These variables may have contributed to the observed variations in surgical technique and other perioperative measures. To fully understand the factors influencing surgical technique selection and to explore the rationale behind surgeons' decisions regarding perioperative applications, future studies should delve deeper into the decision-making process of individual surgeons such as training, experience, exposure to different techniques, and institutional protocols, patient characteristics, and available resources. This will provide valuable insights into the factors that influence surgical practice and potentially identify opportunities for standardization.\\u003c/p\\u003e\\u003cp\\u003eAs conclusion, despite advancements in surgical techniques and perioperative care, significant inter-institutional variations were observed in the management of grade III and IV HD. Multivariate analysis revealed that while patient and disease-related factors, with the exception of thrombosed HD, did not significantly influence the choice of surgical technique, hospital category emerged as a major determinant of surgical technique and all other aspects of perioperative management, suggesting that institutional factors play a crucial role in shaping clinical practice.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003col\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eSubstantial contributions to conception and design, or analysis and interpretation of data: MO, MK,\\u0026nbsp;\\u003c/strong\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eAcquisition of data: MK, OA, HB, ST, AT, IS, OC, NS, NCA, CT, RK, AEY, TG, SM, FMH, AS, NB, SL, RK, OA, MK, SK, HFK, NCA, MO\\u003c/strong\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eDrating the article or revising it critically for important intellectual content: M.O., M.K,\\u003c/strong\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eFinal approval of the version to be published: M.O.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict of interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they did not receive any financial and non-financial interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;Funding Declaration\\u003c/strong\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they did not receive any funding\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical approval\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIstanbul Medipol University Research Committee granted the study and Institutional Ethics Committee approved the protocol (Protocol number: E-10840098-772.02-3634) in compliance with the Declaration of Helsinki.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eHuman ethics and consent to participate declaration\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the Declaration of Helsinki. All participants provided informed consent prior to their inclusion in the study. Participation was voluntary, and participants could withdraw at any time without repercussions.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eRiss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215-220. \\u003c/li\\u003e\\n\\u003cli\\u003eAgarwal N, Singh K, Sheikh P, Mittal K, Mathai V, Kumar A. Executive Summary - The Association of Colon \\u0026amp; Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016. Indian J Surg. 2017;79(1):58-61. \\u003c/li\\u003e\\n\\u003cli\\u003eTournu G, Abramowitz L, Couffignal C, et al. Prevalence of anal symptoms in general practice: a prospective study. BMC Fam Pract. 2019;20(1):14.\\u003c/li\\u003e\\n\\u003cli\\u003eAbramowitz L, Benabderrahmane M, Pospait D, Philip J, Laou\\u0026eacute;nan C. The prevalence of proctological symptoms amongst patients who see general practitioners in France. Eur J Gen Pract. 2014;20(4):301-306. \\u003c/li\\u003e\\n\\u003cli\\u003eR\\u0026oslash;rvik H, et al. Hemorrhoidal Disease Symptom Score and Short Health ScaleHD: New Tools to Evaluate Symptoms and Health-Related Quality of Life in Hemorrhoidal Disease. Dis Colon Rectum. 2019;62:333-342. \\u003c/li\\u003e\\n\\u003cli\\u003eGoligher JC. Surgery of the Anus, Rectum and Colon. 4th ed. London, United Kingdom: Balli\\u0026egrave;re Tindall; 1980.\\u003c/li\\u003e\\n\\u003cli\\u003eBrillantino A, Renzi A, Talento P, Brusciano L, Marano L, Grillo M, et al. The Italian Unitary Society of Colo-Proctology (Societa Italiana Unitaria di Colonproctologia) guidelines for management of acute and chronic hemorrhoidal disease. Ann Coloproctol 2024;40(4):287-320.\\u003c/li\\u003e\\n\\u003cli\\u003eCoremans G, Denis MA, Dewint P, Duinslaegar M, Gijsen I, et al. Belgian consensus guideline on management of hemorrhoidal disease. Acta Gastroenterol Belg 2021;84(1):101-120.\\u003c/li\\u003e\\n\\u003cli\\u003eGallo G, Martellucci J, Sturiale A, Clerico G, Nilitos G, Marinos F, et al. Consensus tatement of Italian Society of Colorectal Surgery (SICCR) management and treatment of hemorrhoidal disease. Techniques in Coloproctol 2020;24:145-164.\\u003c/li\\u003e\\n\\u003cli\\u003eHawkins AT, Davis BR, Bhama AR, Fang SH, Dawes AJ, Feingold DL, Lightner AL, Paquette IM; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2024 May 1;67(5):614-623\\u003c/li\\u003e\\n\\u003cli\\u003eKim BG, Kang H. The effect of preemptive perianal ropivacaine and ropivacaine with dexmedetomidine on pain after hemorrhoidectomy: a prospective, randomized, doble-blind, placebo-controlled study. Indian J Surg 2014;76(1):49-55.\\u003c/li\\u003e\\n\\u003cli\\u003eMallmann C, Langenbach MR, Florescu RV, K\\u0026ouml;hler A, Barkus J, Ritz JP, et al. Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial. Int J Colorect Dis 2023;38(1):62.\\u003c/li\\u003e\\n\\u003cli\\u003eLin CY, Liu YC, Chen JP, Hsu PH, Chang SL. General anesthesia with local infiltration reduces urine retention rate and prolongs analgesic effect than spinal anesthesia for hemorrhoidectomy. Front Surg 2024;11:1288023.\\u003c/li\\u003e\\n\\u003cli\\u003eRoxas MF, Delima MG. Randomized controlled trial to determine the effectiveness of Nivatvongs technique versus conventional local anaesthetic infiltration for outpatient haemorrhoidectomy. Asian J Surg 2006;29(2):70-3.\\u003c/li\\u003e\\n\\u003cli\\u003eNystr\\u0026ouml;m PO, Qvist N, Raahave D, Lindsey I, Mortensen N; Stapled or Open Pile Procedure (STOPP) trial study group. Randomized clinical trial of symptom control after stapled ano-pexy or diathermy excision for haemorrhoid prolapse. Br J Surg. 2010;97:167\\u0026ndash;176\\u003c/li\\u003e\\n\\u003cli\\u003eHjortswang H, J\\u0026auml;rnerot G, Curman B, et al. The Short Health Scale: a valid measure of subjective health in ulcerative colitis. Scand J Gastroenterol. 2006;41:1196-1203. \\u003c/li\\u003e\\n\\u003cli\\u003eLakmal K, Basnayake O, Jayarajah U, Samarasekera D. Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review. World J Surg. 2021;45:1222-1236. https://doi:10.1007/s00268-020-05923-2.\\u003c/li\\u003e\\n\\u003cli\\u003eWang J, Chang-Chien C, Chen J, Lai C, Tang R. The role of lasers in hemorrhoidectomy. Dis Colon Rectum. 1991;34:78-82. https://doi:10.1007/BF02050213.\\u003c/li\\u003e\\n\\u003cli\\u003eWee IJY, Koo CH, Seow-En I, Ng YYR, Lin W, Tan EJK. Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis. Ann Coloproctol. 2023;39(1):3-10. https://doi:10.3393/ac.2022.00598.0085.\\u003c/li\\u003e\\n\\u003cli\\u003eCemil A, Ugur K, Salih GM, Merve K, Guray DM, Emine BS. Comparison of Laser Hemorrhoidoplasty and Milligan-Morgan Hemorrhoidectomy Techniques in the Treatment of Grade 2 and 3 Hemorrhoidal Disease. Am Surg. 2024;90(4):662-671. https://doi:10.1177/00031348231207301.\\u003c/li\\u003e\\n\\u003cli\\u003eKarkalemis K, Chalkias PL, Kasouli A, Chatzaki E, Papanikolaou S, Dedemadi G. Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease. Langenbecks Arch Surg. 2021;406(7):2489-2495. \\u003c/li\\u003e\\n\\u003cli\\u003eChan KK, Arthur JD. External haemorrhoidal thrombosis: evidence for current management. Tech Coloproctol. 2013;17:21\\u0026ndash;25.).\\u003c/li\\u003e\\n\\u003cli\\u003eDe Schepper H, Coremans G, Denis MA, et al. Belgian consensus guideline on the management of hemorrhoidal disease. Acta Gastro-enterologica Belgica. 2021 Jan-Mar;84(1):101-120\\u003c/li\\u003e\\n\\u003cli\\u003eAcheson AG, Ng OCT. Haemorrhoidal disease. In: Sagar PM, Hill AG, Knowles CH, et al, eds. Keighley and Williams\\u0026apos; Surgery of the Anus, Rectum \\u0026amp; Colon. 4th ed. Boca Raton, FL: CRC Press; 2019:195-219.\\u003c/li\\u003e\\n\\u003cli\\u003eRubbini M, Ascanelli S. Classification and guidelines of hemorrhoidal disease: Present and future. World J Gastrointest Surg. 2019 Mar 27;11(3):117-121\\u003c/li\\u003e\\n\\u003cli\\u003eMorgado PJ, Su\\u0026aacute;rez JA, G\\u0026oacute;mez LG, Morgado PJ., Jr Histoclinical basis for a new classification of hemorrhoidal disease. Dis Colon Rectum. 1988;31:474\\u0026ndash;480.\\u003c/li\\u003e\\n\\u003cli\\u003eGerjy R, Lindhoff-Larson A, Nystr\\u0026ouml;m PO. Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients. Colorectal Dis. 2008;10:694\\u0026ndash;700.\\u003c/li\\u003e\\n\\u003cli\\u003eLohsiriwat V. Treatment of hemorrhoids: A coloproctologist\\u0026apos;s view. World J Gastroenterol. 2015;21:9245\\u0026ndash;9252.\\u003c/li\\u003e\\n\\u003cli\\u003eElbetti C, Giani I, Novelli E, Fucini C, Martellucci J. The single pile classification: a new tool for the classification of haemorrhoidal disease and the comparison of treatment results. Updates Surg. 2015;67:421\\u0026ndash;426.\\u003c/li\\u003e\\n\\u003cli\\u003eRubbini M, Ascanelli S, Fabbian F. Hemorrhoidal disease: is it time for a new classification? Int J Colorectal Dis. 2018;33:831\\u0026ndash;833.\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003ccite\\u003eR\\u0026oslash;rvik HD, Styr K, Ilum L, McKinstry GL, Dragesund T, Campos AH, Brandstrup B, Olaison G. Hemorrhoidal Disease Symptom Score and Short Health ScaleHD: New Tools to Evaluate Symptoms and Health-Related Quality of Life in Hemorrhoidal Disease. Dis Colon Rectum. 2019;62:333\\u0026ndash;342\\u003c/cite\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Table 2\",\"content\":\"\\u003cp\\u003eTable 2 is available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"langenbecks-archives-of-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"laos\",\"sideBox\":\"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)\",\"snPcode\":\"423\",\"submissionUrl\":\"https://submission.nature.com/new-submission/423/3\",\"title\":\"Langenbeck's Archives of Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Hemorrhoidal disease, hemorrhoidectomy, hemorrhoid surgery\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6981998/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6981998/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose:\\u003c/h2\\u003e\\u003cp\\u003eWith multiple treatment options available for hemorrhoidal disease (HD), identifying factors that influence surgical and perioperative management decisions is essential, particularly in advanced cases. This study aimed to determine the patient and disease-related determinants affecting the choice of surgical technique and perioperative management in patients with Grade III and IV HD, thereby addressing inter-institutional variations in treatment approaches.\\u003c/p\\u003e\\u003ch2\\u003eMethods:\\u003c/h2\\u003e\\u003cp\\u003eA secondary analysis was performed on data from a nationwide, multicenter prospective cohort study. The study included 315 patients diagnosed with Grade III (72%) and Grade IV (28%) HD, with a mean age of 43.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;11.4 years and a male predominance (76.7%). Preoperative data, including patient demographics, comorbidities (ASA scores), symptom severity, and clinical findings, were collected at participating governmental and private hospitals. Surgical techniques were classified as excisional or non-excisional, while anesthesia type, use of perianal or pudendal analgesia, and hospitalization duration were determined by the surgical teams. Hospital type was also recorded. Multivariable analyses were conducted to identify factors influencing the choice of surgical techniques, anesthesia, analgesia application, and the decision for outpatient procedures.\\u003c/p\\u003e\\u003ch2\\u003eResults:\\u003c/h2\\u003e\\u003cp\\u003eMultivariate analysis revealed that the presence of thrombosis significantly influenced the choice of surgical technique (OR: 7.2, CI: 2.8\\u0026ndash;12.7, p\\u0026thinsp;=\\u0026thinsp;0.001), while hospital category also played an important role (OR: 5.1, CI: 2.7\\u0026ndash;9.7, p\\u0026thinsp;=\\u0026thinsp;0.001). For anesthesia type, factors such as disease grade (OR: 3.3, CI: 1.6\\u0026ndash;6.7, p\\u0026thinsp;=\\u0026thinsp;0.001), hospital category (OR: 9, CI: 4.1\\u0026ndash;19.9, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), and surgical technique (OR: 6.8, CI: 3\\u0026ndash;15.3, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) were significant determinants. The decision to use perianal or pudendal analgesia was influenced by hospital category (OR: 27.1, CI: 11.7\\u0026ndash;62.6, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and the presence of incontinence (OR: 0.2, CI: 0.04\\u0026ndash;0.93, p\\u0026thinsp;=\\u0026thinsp;0.04). Outpatient management was associated with disease grade (OR: 2.3, CI: 1.1\\u0026ndash;4.8, p\\u0026thinsp;=\\u0026thinsp;0.023), hospital category (OR: 2, CI: 1.2\\u0026ndash;3.2, p\\u0026thinsp;=\\u0026thinsp;0.011), higher comorbidity (ASA\\u0026thinsp;\\u0026ge;\\u0026thinsp;3, OR: 3.3, CI: 1.8\\u0026ndash;3.2, p\\u0026thinsp;=\\u0026thinsp;0.007), and the selected surgical technique (OR: 3.1, CI: 1.6\\u0026ndash;5.8, p\\u0026thinsp;=\\u0026thinsp;0.001).\\u003c/p\\u003e\\u003ch2\\u003eConclusion:\\u003c/h2\\u003e\\u003cp\\u003eSignificant inter-institutional variations exist in the management of advanced HD. Among various factors, the presence of thrombosis emerges as the predominant determinant in surgical decision-making, providing valuable insights for standardizing treatment protocols and reducing practice variability.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Determinants Influencing Decision-Making for Operative and Perioperative Management of Grade III and IV Hemorrhoidal Disease: Secondary Analysis of a Multicenter Nationwide Prospective Cohort Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-08-27 11:01:55\",\"doi\":\"10.21203/rs.3.rs-6981998/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-03-07T09:00:55+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-05T23:31:05+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-19T10:12:01+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"215646124619844244269596428979619661121\",\"date\":\"2026-02-15T22:47:12+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"195791953031688892813242887718607780485\",\"date\":\"2026-02-10T04:24:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"269295962801008201394346886986269058054\",\"date\":\"2026-02-08T20:18:22+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-08-19T11:45:01+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-06-30T09:00:29+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-06-30T07:42:31+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Langenbeck's Archives of Surgery\",\"date\":\"2025-06-26T09:32:08+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"langenbecks-archives-of-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"laos\",\"sideBox\":\"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)\",\"snPcode\":\"423\",\"submissionUrl\":\"https://submission.nature.com/new-submission/423/3\",\"title\":\"Langenbeck's Archives of Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"7bc0902f-a8a6-4d89-bcdf-7cfdadb31383\",\"owner\":[],\"postedDate\":\"August 27th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-20T16:10:13+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6981998\",\"link\":\"https://doi.org/10.1007/s00423-026-04030-5\",\"journal\":{\"identity\":\"langenbecks-archives-of-surgery\",\"isVorOnly\":false,\"title\":\"Langenbeck's Archives of Surgery\"},\"publishedOn\":\"2026-04-15 15:58:53\",\"publishedOnDateReadable\":\"April 15th, 2026\"},\"versionCreatedAt\":\"2025-08-27 11:01:55\",\"video\":\"\",\"vorDoi\":\"10.1007/s00423-026-04030-5\",\"vorDoiUrl\":\"https://doi.org/10.1007/s00423-026-04030-5\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6981998\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6981998\",\"identity\":\"rs-6981998\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}