Laser Hemorrhoidoplasty: Two-Year outcomes from a Prospective Observational Cohort Study

Laser Hemorrhoidoplasty: Two-Year outcomes from a Prospective Observational 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 Laser Hemorrhoidoplasty: Two-Year outcomes from a Prospective Observational Cohort Study Osama Elhardello, Ayesha Hamed, Ahmed Abdelhady, Mohamed K. Alhanafy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8931307/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: This study aimed at analysing the outcomes of laser hemorrhoidoplasty (LHP) in a 2-year period. Methods: LHP was carried out in 77 patients (83% of them had grade III or grade IV) treated over a two-year period. Inclusion criteria were an age above 18 years old, symptomatic haemorrhoids of grade 2 to 4 with minimal to moderate prolapse. Post operative pain, recurrence of the disease, recurrence of symptoms, complications, length of stay and patients’ satisfaction were all documented. Results: The procedure was found to be safe, well tolerated, and associated with commending short to medium-term outcomes. Over 90% of patients achieved complete and sustained symptom resolution over a period of 1 year follow up despite the predominance of advanced disease in this group of patients. Disease recurrence occurred in 9.1% of the patients, postoperative pain was minimal, with a low mean pain score and limited use of opioids. Hospital stay was 1 day in most patients, and most patients returned to normal activities within the first postoperative week. 81% of the patients were highly satisfied, and 90% of patients reporting satisfactory outcomes. Postoperative complications occurred in an only one patient who had a submucosal abscess that required surgical intervention. Regression analysis showed no association between hemorrhoidal grade, symptom duration, and postoperative complications or recurrence rate. Conclusion: Those outcomes support LHP as a durable minimally invasive procedure in the short to medium term. It is found to be an effective treatment option, even in patients with advanced hemorrhoidal disease. Laser hemorrhoidoplasty hemorrhoids Pain score minimally invasive hemorrhoidectomy Figures Figure 1 Introduction Haemorrhoids are a common disease that affects millions of people around the globe. Worldwide, the prevalence of symptomatic haemorrhoids is estimated at 4.4% in the general population [ 1 ]. The prevalence in Kuwait is said to be high, but no exact data is available. The fact that the country has a high rate of obesity per capita [ 2 ], makes this suggestion likely [ 3 ]. Though of the benign nature of the disease, it causes significant distracting symptoms to patients as bleeding, discharge, itching and swelling. Management depends on patients’ factors and the disease grade. Surgery is mostly indicated after failure of conservative management or high disease grades (grade 3 and 4 on Banov grading) [ 4 ]. Surgery for haemorrhoids was first described in 460 BC by Hippocrates [ 5 ] and has been evolving ever since. Excision whether open or closed is regarded as the gold standard procedure, but many other procedures with a less invasive approach came recently into practice. Excisional procedures are notoriously known for being painful and with more complication rates [ 6 ]. Minimally invasive procedures cause less damage to the tissues and hence associated with less post-operative pain. Though of their impressive short-term outcomes, in the long term minimally invasive procedures are said to have a higher rate of recurrence [ 7 ]. The ideal procedure for haemorrhoids should bear less pain and complications in the short term and be effective with a lesser rate of recurrence in the long term. Laser hemorrhoidoplasty (LHP) was first described between 2007 and 2009 [ 8 ]. It involves direct application of the Laser energy to the haemorrhoidal plexus in the submucosal layer of the anal canal. The diode Laser deployed at a wavelength of 1470 nm, induces photocoagulation in the hemorrhoidal cushions which results in their shrinkage and sealing of the feeding vessels. Later, fibrosis and tissue remodelling result in diminution in the size of the haemorrhoids and reduction in their volume in weeks after the procedure [ 9 ]. LHP is proven to be more tolerable than conventional haemorrhoidectomy with superior quality of life and comparable moderate term efficacy [ 10 ]. Many studies have shown that LHP resulted in in minimal postoperative pain, successful resolution of symptoms as bleeding and prolapse in up to 97% of the patients. It was also associated with early return to work and higher patients’ satisfaction [9&10]. Given that emerging evidence is mounting to support the use of LHP, the aim of this paper is to present our short- and medium-term outcomes for the procedure in our centre. Methods Between February 2023 and April 2025, prospective data were collected for 77 patients who underwent LHP. The study received approval from the institution's internal ethics committee. Due to its retrospective design, the requirement for informed consent was waived. This prospective cohort study followed the STROBE guidelines, and the corresponding checklist was completed. Inclusion criteria were an age above 18 years old, symptomatic haemorrhoids of grade 2 to 4 with minimal to moderate prolapse. All patients had their clinical evaluation (history and clinical examination including proctoscopy/colonoscopy if needed), necessary investigations and the anaesthetic evaluations done before the operation. Patients were seen in clinic on day 3-, 7- and 3-month, then followed up to 2 years post-surgery. Short term follow up was completed for all patients from the day of surgery to 3 months post-surgery. Complete resolution or good improvement of symptoms, patient’s satisfaction, recommendation of the operation and ability to perform daily activities. A standardized question sheet was used to gather information related to symptoms. Clinical examination was used to detect recurrence/compilations. All patients underwent LHP, a group of 5 surgeons trained on LHP operated on the patients. All procedures were done under general anaesthesia. Examination under anaesthesia and mapping of the field were performed, where a mark was put at the base of each hemorrhoidal column. A small incision was done using electrocautery at the site of the mark to allow the entrance of the Laser probe. A Biolitic Laser system with a Ceralas E 1472 nm was used. Dissection of the submucosal space was done using an artery forceps to a point about 3 to 4 cm above the dentate line for every targeted column. Then the radial probe was admitted and advanced to burn the created space. The power of the machine was set to 8 Joules, and a pulse mode was used with an active interval of 3 seconds. Each column would have received 2 to 4 intervals depending on the size of the column. Ice packs were used to dissipate the heat after treating each column. Local anaesthetic infiltrations and pudendal blocks were done for most patients. Operative data as the grade of the haemorrhoid, number of columns treated, total energy used for each patient, and additional procedures were all documented. Most patients were discharged home on the next day (as this is the hospital policy) on antibiotics and NSAIDs. Statistical analysis: Data analysis was performed using SPSS software, version 26, on an IBM-compatible computer. Categorical variables were presented as counts (N) and percentages (%) and assessed using the Chi-square test (χ²) or Fisher’s Exact test when expected cell counts were below five. Continuous variables were reported as mean, standard deviation (SD), and range (minimum–maximum). For comparisons between two groups, normally distributed data were analysed using the student’s t-test, while non-normally distributed data were assessed using the Mann-Whitney U test. A two-tailed p-value of less than 0.05 was considered statistically significant. Results Demographic data: The patients were between 21 and 78 years with a median age of 40.6 (± 10.5) years. Among them, 34 (44.2%) were males and 43 (55.8%) were females (Table 1). Haemorrhoids grades were distributed as follows: 13 patients (16.8%) had grade II, 37 (48.1%) had grade III, and 27 (35.1%) had grade IV on Goligher grading system. Grade III haemorrhoids were the most prevalent (Table 1). The primary presenting symptoms were swelling and pain, reported in 48 (62.3%) and 49 (63.6%) patients, respectively. Additionally, bleeding was observed in 41 patients (53.2%). Notably, most patients experienced a combination of swelling, pain, and bleeding. The duration of hemorrhoidal symptoms varied by grade and individual patient factors, with a mean duration of 124.9 ± 70.4 days, ranging from 3 to 365 days (Table 1). Perioperative data Regarding the intraoperative data, the total energy used varied based on the hemorrhoidal grade, and the number of columns treated, with a mean total energy of 1032.7 ± 319.3 Joules, ranging from 403 to 1600 Joules. The number of treated columns ranged from 2 to 7 columns with a mean of 3.5 ± 1.1 columns per patient. No intraoperative adverse events were reported, and all procedures were completed smoothly without intraoperative complications. The operative time data was not consistently documented for a significant portion of patients and was therefore excluded from the analysis (Table 2). Hospital stays ranged between one and three days with a mean of (1.9 ± 0.4) (Table 3). Return to normal activities occurred within the 1st week. It worth mentioning here that our hospital protocol is for these patients to be admitted for an overnight stay rather than being discharged on the same day. All patients were fit to be discharged on the next day and the ones who remained were there for nonclinical reasons. Postoperative outcomes Postoperative pain was evaluated using VAS (Visual Analogue Scale) score after 12 hours postoperatively, ranging from 0 to 6 with a mean of (1.6 ± 1.2). A minority of patients 4 (5.2%) required postoperative opioid use which represents how comfortable and well tolerated was the procedure (Table 3). Recurrence of symptoms was encountered in 17 (22.1%) patients. This included rectal bleeding, long term pain, and persistent swelling. Postoperative bleeding presented as spotting following defecation of either fresh blood in the first few days or pink coloured fluid, without any severe episodes requiring intervention. It was observed in 9 patients (11.7%) after 8 weeks. Among them, 5 responded to conservative treatment, while in 4 patients the bleeding persisted for 6 months and was classified as recurrence. 2 patients had persistent anal discharge for 3 months and resolved spontaneously with conservative measures (Table 3). Persistent postoperative swelling lasting over 6 months occurred in 7 patients (9.1%) and was also considered a recurrence. Prolonged anal pain beyond 30 days post-surgery affected 8 patients (10.4%), but most cases were managed conservatively. It is important to note that some patients experienced more than one symptom recurrence (Table 3). Post operative complications included one patient who had an anal abscess 7 days post-surgery, the patient required incision and drainage under general anaesthesia, no cases of stool or flatus incontinence, stenosis, nor urinary outflow issues were reported in this study (Table 3). Recurrence was defined as the persistence of hemorrhoidal tissue or the reappearance/ persistence of symptoms such as bleeding, pain, or prolapse lasting more than six months, as confirmed by clinical and proctoscopic evaluation. Recurrence was identified in 7 patients (9.1%) at the 1-year follow-up (Table 3). Patient satisfaction was high, with 63 patients (81.8%) reporting being satisfied, while 7 patients (9.1%) expressed moderate satisfaction, and another 7 patients (9.1%) were dissatisfied due to persistent or recurrent symptoms (Fig. 1). Further analysis using multilinear regression revealed no significant correlation between haemorrhoid grade (P = 0.800), symptom duration (P = 0.321), or patient demographic factors and the development of postoperative complications. However, a significant association was noted between the postoperative pain score (P = 0.005), length of hospital stays (P = 0.001), and the occurrence of postoperative adverse events. Although higher energy application appeared to be linked to complications, the association did not reach statistical significance (P = 0.231), possibly due to the small sample size (see Table 4). Moreover, there was no observed relationship between demographic data, clinical presentation, surgical variables, and recurrence at the one-year follow-up (Table 5). Discussion This study aimed to contribute to the growing body of evidence on laser hemorrhoidoplasty (LHP) by evaluating patients’ outcomes over a two-year follow-up period. As a prospective observational cohort study, it provides mid-term outcome data for a cohort predominantly composed of patients with advanced hemorrhoidal disease. The application of laser for treating haemorrhoids was first introduced in the 1970s and was developed over the years to the current novel methods of LHP and Hemorrhoidal Laser Procedure (HELP). The diode laser is deployed directly to the submucosal hemorrhoidal cushions in LHP. It causes photocoagulation and thus retraction of the hemorrhoidal cushions. Because of its precision and small filed of power (1mm diameter around the point of application) the risk of damage to deeper structures is minimal [ 11 ]. Thermal energy causes thrombosis of the venous plexus and obliteration the hemorrhoidal cushions, with adherence of the rectal mucosa and submucosal layers muscular layers. The result would be fibrosis and tissue remodelling during the healing process that would eventually cause reduction in the volume and obliteration of the hemorrhoidal tissues. In the short-term, LHP is known to be highly effective in terms of symptoms relief and reduction of prolapsed haemorrhoids. In our cohort, the procedure was well tolerated with low pain score on the VAS, consequently patients’ satisfaction was described as high in 81% of the patients. This finding obviously replicates the growing literature evidence that LHP causes minimal pain and is met with high satisfaction in the short to medium-term. Moreover, return to normal activities was reasonably quick and nearly all our patients returned to normal activities in the first few days after the procedure. Similar findings have been reported in previous studies, underscoring the value of non-excisional techniques for the management of hemorrhoidal disease [12&13]. In contrast, excisional procedures are frequently associated with delayed recovery due to postoperative pain, discharge, and wound-related symptoms. Symptoms’ recurrence occurred in 17 patients (22.1%) in the form of bleeding, discharge or persistent swelling. In one third of these patients, the symptoms persisted to become a florid recurrence of a clinically evident hemorrhoidal disease over time (6–12 months). This symptom recurrence rate was not far from what was described by Wee et al in their systematic review as 28.6% symptoms recurrence rate [ 12 ]. Their review involved only patients with grade 2 or 3 haemorrhoids. The finding that over 75% of the patients had complete resolution of symptoms and suffered no recurrence of symptoms in a cohort where 83% of the patients had and advanced disease presenting as grade 3 to 4 piles adds further prove to the efficacy of LHP. Bleeding was the most common symptom among patients with recurrence of symptoms, accounting for approximately half of cases. In four patients, bleeding persisted beyond two months and was subsequently associated with confirmed disease recurrence. Brusciano et al described post defecatory bleeding after the procedure in up to 60% of their patients following LHP, however, this was limited to the first postoperative week and did not require intervention [ 14 ]. Together with our findings, this supports the coagulative and haemostatic properties of LHP. We quoted one complication that needed taking the patient back to theatres and that was a patient who developed a small submucous abscess on day 3 post-procedure. This was diagnosed by pelvic MRI and managed successfully with incision and drainage. Bleeding remains the most frequently reported complication following LHP in the literature [ 15 ]. Longchamp et al quoted in their systematic review an overall rate of complications post-LHP to be 64%. however, the majority were minor, with only 0.9% requiring reintervention that needed return to theatres [ 16 ]. In the literature, reported complication rates vary widely, ranging from 10% to 42%, largely due to heterogeneity in definitions [16&17]. This discrepancy is mostly to do with the way authors refer to what is a complication, as many authors [ 18 ] regarded symptoms’ recurrence and recurrence of the disease as complications. On the other hand, others differentiate between the recurrence of symptoms and the true complications as bleeding, abscess formation and sphincter disturbance. Faes et al., in one of the larger long-term studies, reported an 18% complication rate at five years of follow-up [ 13 ]. In our cohort, the recurrence rate at one year was 9.1%, which aligns with the findings of Longchamp et al., who reported one-year recurrence rates ranging from 0% to 11.3% [ 16 ]. Despite the encouraging results of LHP there yet to be a consensus on the optimum operative parameters for the procedure. Like the amount of energy to be used (more or less than 500 J per column) and the different entry points (skin Vs haemorrhoids) [19&20]. In our study the mean total energy delivered per patient was 1032 J with an average number of treated columns of 3 columns. This makes the average amount of energy per column around 300 to 350 J. No direct complication was ascribed to this amount of energy used in our cohort. Our study is met with several limitations that made it not suitable for drawing conclusions around LHP. It is a single centre experience with a relatively small sample size. The follow up period is only for 2 years. We didn’t compare the procedure to any of the none-excisional procedures in use. Though we feel it’s an important addition to the growing number of studies assessing the outcomes of use of LHP. We quoted the outcomes in a cohort dominated by patients with advanced disease (grade 3 and 4 haemorrhoids) whereas most of the studies reported outcomes for patients with grade 2 to 3 haemorrhoids. We feel this study adds meaningful evidence to the growing literature supporting LHP. and emphasizes the need for larger, comparative, long-term studies to better define its role among non-conventional hemorrhoidal treatments. Conclusion LHP demonstrated favourable outcomes with low postoperative pain levels, minimal opioid requirements, and short hospital stays, reflecting good patient tolerance and comfort. It revealed a very low postoperative complication rate with a high degree of patient satisfaction. While recurrence of symptoms was observed in 22.1% of cases, true recurrence; defined as persistent symptoms beyond six months was limited to 9.1%. These findings support the procedure’s safety, efficacy, and positive impact on patient recovery and quality of life. However, larger scale randomized clinical trials are still required to validate our findings. Declarations Acknowledgments: None Financial support and sponsorship: None Conflicts of interest: The authors declare that they have no conflict of interest. Human Ethics: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Review Board of Al Salam Hospitals. Consent to participate: Due to the retrospective data collection of this study, the informed consent was waived. Clinical trial number: not applicable. References Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, Stift A (2012) The prevalence of hemorrhoids in adults. International journal of colorectal disease. 2012;27:215 – 20 Al Sabah S et al (2020) Results from the first Kuwait National Bariatric Surgery. BMC Report’Surgery 20(1). 10.1186/s12893-020-00946-x Huang J, Gui Y, Qin H, Xie Y (2023) Causal association between adiposity and hemorrhoids: a Mendelian randomization study. Front Med (Lausanne). 2023;10:1229925. 10.3389/fmed.2023.1229925 . PMID: 37869154; PMCID: PMC10587414 Banov L Jr, Knoepp LF Jr, Erdman LH, Alia RT (1975) Management of hemorrhoidal disease. Journal of the South Carolina Medical Association 1985;81(7):398–401. PMID: 3861909 Hippocrates, Adams F (1985) The genuine works of Hippocrates. Classics of Medicine Library, Birmingham, Ala Correll D, Barreveld A (2013) Faculty opinions recommendation of pain intensity on the first day after surgery: A prospective cohort study comparing 179 surgical procedures. Fac Opinions – Post-Publication Peer Rev Biomedical Literature. [Preprint] 10.3410/f.718042649.793480773 Simillis C et al (2015) Systematic Review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for Haemorrhoids. Br J Surg 102(13):1603–1618. 10.1002/bjs.9913 Plapler H (2008) A new method for hemorrhoid surgery: Experimental model of diode laser application in monkeys. Photomed Laser Surg 26(2):143–146. 10.1089/pho.2007.2121 Karahaliloğlu AF (2010) ‘Laser Hemorrhoidoplasty (LHP)’, coloproctology , 32(2), pp. 116–123. 10.1007/s00053-010-0084-9 Tan VZ et al (2022) Systematic Review and meta-analysis of postoperative pain and symptoms control following laser haemorrhoidoplasty versus Milligan-Morgan haemorrhoidectomy for symptomatic haemorrhoids: A new standard. Int J Colorectal Dis 37(8):1759–1771. 10.1007/s00384-022-04225-4 De Nardi P et al (2016) Hemorrhoid laser procedure for second- and third-degree hemorrhoids: Results from a Multicenter Prospective Study. Tech Coloproctol 20(7):455–459. 10.1007/s10151-016-1479-6 Wee IJ et al (2023) Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for Grade II/III hemorrhoids: A systematic review and meta-analysis. Annals Coloproctology 39(1):3–10. 10.3393/ac.2022.00598.0085 Faes S et al (2019) Short- and long‐term outcomes of Laser Haemorrhoidoplasty for grade ii–iii haemorrhoidal disease. Colorectal Dis 21(6):689–696. 10.1111/codi.14572 Brusciano L et al (2019) Postoperative discomfort and pain in the management of hemorrhoidal disease: Laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids. Updates Surg 72(3):851–857. 10.1007/s13304-019-00694-5 Lim SY, Rajandram R, Roslani AC (2022) Comparison of post-operative bleeding incidence in laser hemorrhoidoplasty with and without hemorrhoidal artery ligation: a double-blinded randomized controlled trial. BMC Surg. 2022;22(1):146. 10.1186/s12893-022-01594-z . PMID: 35449097; PMCID: PMC9022276 Longchamp G et al (2020) Non-excisional laser therapies for hemorrhoidal disease: A systematic review of the literature. Lasers Med Sci 36(3):485–496. 10.1007/s10103-020-03142-8 Plapler H et al (2009) A new method for hemorrhoid surgery: Intrahemorrhoidal diode laser, does it work? Photomed Laser Surg 27(5):819823. 10.1089/pho.2008.2368 Boerhave NHP, Klicks RJ, Dogan K (2023) The efficacy of laser haemorrhoidoplasty (LHP) in the treatment of symptomatic haemorrhoidal disease: An observational cohort study. Colorectal Dis. 2023;25(6):1202–1207. 10.1111/codi.16514 . Epub 2023 Feb 28. PMID: 36757069 Weyand G et al (2017) ‘Laserhämorrhoidoplastie mit dem 1470-nm-diodenlaser in der behandlung des zweit- bis viertgradigen hämorrhoidalleidens – eine kohortenstudie mit 497 Fällen’, Zentralblatt für Chirurgie - Zeitschrift für Allgemeine, Viszeral-, Thorax- und Gefäßchirurgie , 144(04), pp. 355–363. 10.1055/s-0043-120449 Poskus T et al (2020) Results of the double-blind randomized controlled trial comparing laser hemorrhoidoplasty with sutured mucopexy and excisional hemorrhoidectomy. Int J Colorectal Dis 35(3):481–490. 10.1007/s00384-019-03460-6 Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Apr, 2026 Reviews received at journal 30 Mar, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 09 Mar, 2026 Editor assigned by journal 08 Mar, 2026 Submission checks completed at journal 06 Mar, 2026 First submitted to journal 21 Feb, 2026 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-8931307","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":604690990,"identity":"fabd68f2-a341-4af1-9f93-1a0f457dc4f2","order_by":0,"name":"Osama Elhardello","email":"","orcid":"","institution":"Al Salam Al Assima hospital","correspondingAuthor":false,"prefix":"","firstName":"Osama","middleName":"","lastName":"Elhardello","suffix":""},{"id":604690991,"identity":"444b2947-b2da-44ae-9f4b-f89908f9a8ed","order_by":1,"name":"Ayesha Hamed","email":"","orcid":"","institution":"Al Salam Al Ahmadi hospital","correspondingAuthor":false,"prefix":"","firstName":"Ayesha","middleName":"","lastName":"Hamed","suffix":""},{"id":604690992,"identity":"ab115d71-1028-449b-9b4e-ded3e8e223b2","order_by":2,"name":"Ahmed Abdelhady","email":"","orcid":"","institution":"Al Salam Al Assima hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Abdelhady","suffix":""},{"id":604690993,"identity":"b2973905-d541-4981-9ba3-96e0001a43c6","order_by":3,"name":"Mohamed K. 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Worldwide, the prevalence of symptomatic haemorrhoids is estimated at 4.4% in the general population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence in Kuwait is said to be high, but no exact data is available. The fact that the country has a high rate of obesity per capita [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], makes this suggestion likely [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThough of the benign nature of the disease, it causes significant distracting symptoms to patients as bleeding, discharge, itching and swelling. Management depends on patients\u0026rsquo; factors and the disease grade. Surgery is mostly indicated after failure of conservative management or high disease grades (grade 3 and 4 on Banov grading) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgery for haemorrhoids was first described in 460 BC by Hippocrates [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and has been evolving ever since. Excision whether open or closed is regarded as the gold standard procedure, but many other procedures with a less invasive approach came recently into practice. Excisional procedures are notoriously known for being painful and with more complication rates [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Minimally invasive procedures cause less damage to the tissues and hence associated with less post-operative pain. Though of their impressive short-term outcomes, in the long term minimally invasive procedures are said to have a higher rate of recurrence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe ideal procedure for haemorrhoids should bear less pain and complications in the short term and be effective with a lesser rate of recurrence in the long term. Laser hemorrhoidoplasty (LHP) was first described between 2007 and 2009 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It involves direct application of the Laser energy to the haemorrhoidal plexus in the submucosal layer of the anal canal. The diode Laser deployed at a wavelength of 1470 nm, induces photocoagulation in the hemorrhoidal cushions which results in their shrinkage and sealing of the feeding vessels. Later, fibrosis and tissue remodelling result in diminution in the size of the haemorrhoids and reduction in their volume in weeks after the procedure [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. LHP is proven to be more tolerable than conventional haemorrhoidectomy with superior quality of life and comparable moderate term efficacy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Many studies have shown that LHP resulted in in minimal postoperative pain, successful resolution of symptoms as bleeding and prolapse in up to 97% of the patients. It was also associated with early return to work and higher patients\u0026rsquo; satisfaction [9\u0026amp;10].\u003c/p\u003e \u003cp\u003eGiven that emerging evidence is mounting to support the use of LHP, the aim of this paper is to present our short- and medium-term outcomes for the procedure in our centre.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eBetween February 2023 and April 2025, prospective data were collected for 77 patients who underwent LHP. The study received approval from the institution's internal ethics committee. Due to its retrospective design, the requirement for informed consent was waived. This prospective cohort study followed the STROBE guidelines, and the corresponding checklist was completed. Inclusion criteria were an age above 18 years old, symptomatic haemorrhoids of grade 2 to 4 with minimal to moderate prolapse.\u003c/p\u003e \u003cp\u003eAll patients had their clinical evaluation (history and clinical examination including proctoscopy/colonoscopy if needed), necessary investigations and the anaesthetic evaluations done before the operation.\u003c/p\u003e \u003cp\u003ePatients were seen in clinic on day 3-, 7- and 3-month, then followed up to 2 years post-surgery. Short term follow up was completed for all patients from the day of surgery to 3 months post-surgery. Complete resolution or good improvement of symptoms, patient\u0026rsquo;s satisfaction, recommendation of the operation and ability to perform daily activities.\u003c/p\u003e \u003cp\u003eA standardized question sheet was used to gather information related to symptoms. Clinical examination was used to detect recurrence/compilations.\u003c/p\u003e \u003cp\u003eAll patients underwent LHP, a group of 5 surgeons trained on LHP operated on the patients. All procedures were done under general anaesthesia. Examination under anaesthesia and mapping of the field were performed, where a mark was put at the base of each hemorrhoidal column. A small incision was done using electrocautery at the site of the mark to allow the entrance of the Laser probe. A Biolitic Laser system with a Ceralas E 1472 nm was used. Dissection of the submucosal space was done using an artery forceps to a point about 3 to 4 cm above the dentate line for every targeted column. Then the radial probe was admitted and advanced to burn the created space. The power of the machine was set to 8 Joules, and a pulse mode was used with an active interval of 3 seconds. Each column would have received 2 to 4 intervals depending on the size of the column. Ice packs were used to dissipate the heat after treating each column. Local anaesthetic infiltrations and pudendal blocks were done for most patients.\u003c/p\u003e \u003cp\u003eOperative data as the grade of the haemorrhoid, number of columns treated, total energy used for each patient, and additional procedures were all documented. Most patients were discharged home on the next day (as this is the hospital policy) on antibiotics and NSAIDs.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis:\u003c/h2\u003e \u003cp\u003eData analysis was performed using SPSS software, version 26, on an IBM-compatible computer. Categorical variables were presented as counts (N) and percentages (%) and assessed using the Chi-square test (χ\u0026sup2;) or Fisher\u0026rsquo;s Exact test when expected cell counts were below five. Continuous variables were reported as mean, standard deviation (SD), and range (minimum\u0026ndash;maximum). For comparisons between two groups, normally distributed data were analysed using the student\u0026rsquo;s t-test, while non-normally distributed data were assessed using the Mann-Whitney U test. A two-tailed p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eDemographic data:\u003c/h2\u003e\n \u003cp\u003eThe patients were between 21 and 78 years with a median age of 40.6 (\u0026plusmn;\u0026thinsp;10.5) years. Among them, 34 (44.2%) were males and 43 (55.8%) were females (Table 1).\u003c/p\u003e\n \u003cdiv\u003eHaemorrhoids grades were distributed as follows: 13 patients (16.8%) had grade II, 37 (48.1%) had grade III, and 27 (35.1%) had grade IV on Goligher grading system. Grade III haemorrhoids were the most prevalent (Table 1).\u003c/div\u003e\n \u003cp\u003eThe primary presenting symptoms were swelling and pain, reported in 48 (62.3%) and 49 (63.6%) patients, respectively. Additionally, bleeding was observed in 41 patients (53.2%). Notably, most patients experienced a combination of swelling, pain, and bleeding. The duration of hemorrhoidal symptoms varied by grade and individual patient factors, with a mean duration of 124.9\u0026thinsp;\u0026plusmn;\u0026thinsp;70.4 days, ranging from 3 to 365 days (Table\u0026nbsp;1).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePerioperative data\u003c/h3\u003e\n\u003cp\u003eRegarding the intraoperative data, the total energy used varied based on the hemorrhoidal grade, and the number of columns treated, with a mean total energy of 1032.7\u0026thinsp;\u0026plusmn;\u0026thinsp;319.3 Joules, ranging from 403 to 1600 Joules. The number of treated columns ranged from 2 to 7 columns with a mean of 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 columns per patient. No intraoperative adverse events were reported, and all procedures were completed smoothly without intraoperative complications. The operative time data was not consistently documented for a significant portion of patients and was therefore excluded from the analysis (Table\u0026nbsp;2).\u003c/p\u003e\n\u003cdiv\u003eHospital stays ranged between one and three days with a mean of (1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4) (Table 3). Return to normal activities occurred within the 1st week. It worth mentioning here that our hospital protocol is for these patients to be admitted for an overnight stay rather than being discharged on the same day. All patients were fit to be discharged on the next day and the ones who remained were there for nonclinical reasons.\u003c/div\u003e\n\u003ch3\u003ePostoperative outcomes\u003c/h3\u003e\n\u003cp\u003ePostoperative pain was evaluated using VAS (Visual Analogue Scale) score after 12 hours postoperatively, ranging from 0 to 6 with a mean of (1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2). A minority of patients 4 (5.2%) required postoperative opioid use which represents how comfortable and well tolerated was the procedure (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003eRecurrence of symptoms was encountered in 17 (22.1%) patients. This included rectal bleeding, long term pain, and persistent swelling. Postoperative bleeding presented as spotting following defecation of either fresh blood in the first few days or pink coloured fluid, without any severe episodes requiring intervention. It was observed in 9 patients (11.7%) after 8 weeks. Among them, 5 responded to conservative treatment, while in 4 patients the bleeding persisted for 6 months and was classified as recurrence. 2 patients had persistent anal discharge for 3 months and resolved spontaneously with conservative measures (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003ePersistent postoperative swelling lasting over 6 months occurred in 7 patients (9.1%) and was also considered a recurrence. Prolonged anal pain beyond 30 days post-surgery affected 8 patients (10.4%), but most cases were managed conservatively. It is important to note that some patients experienced more than one symptom recurrence (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003ePost operative complications included one patient who had an anal abscess 7 days post-surgery, the patient required incision and drainage under general anaesthesia, no cases of stool or flatus incontinence, stenosis, nor urinary outflow issues were reported in this study (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003eRecurrence was defined as the persistence of hemorrhoidal tissue or the reappearance/ persistence of symptoms such as bleeding, pain, or prolapse lasting more than six months, as confirmed by clinical and proctoscopic evaluation. Recurrence was identified in 7 patients (9.1%) at the 1-year follow-up (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003ePatient satisfaction was high, with 63 patients (81.8%) reporting being satisfied, while 7 patients (9.1%) expressed moderate satisfaction, and another 7 patients (9.1%) were dissatisfied due to persistent or recurrent symptoms (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003eFurther analysis using multilinear regression revealed no significant correlation between haemorrhoid grade (P\u0026thinsp;=\u0026thinsp;0.800), symptom duration (P\u0026thinsp;=\u0026thinsp;0.321), or patient demographic factors and the development of postoperative complications. However, a significant association was noted between the postoperative pain score (P\u0026thinsp;=\u0026thinsp;0.005), length of hospital stays (P\u0026thinsp;=\u0026thinsp;0.001), and the occurrence of postoperative adverse events. Although higher energy application appeared to be linked to complications, the association did not reach statistical significance (P\u0026thinsp;=\u0026thinsp;0.231), possibly due to the small sample size (see Table 4). Moreover, there was no observed relationship between demographic data, clinical presentation, surgical variables, and recurrence at the one-year follow-up (Table 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to contribute to the growing body of evidence on laser hemorrhoidoplasty (LHP) by evaluating patients\u0026rsquo; outcomes over a two-year follow-up period. As a prospective observational cohort study, it provides mid-term outcome data for a cohort predominantly composed of patients with advanced hemorrhoidal disease.\u003c/p\u003e \u003cp\u003eThe application of laser for treating haemorrhoids was first introduced in the 1970s and was developed over the years to the current novel methods of LHP and Hemorrhoidal Laser Procedure (HELP). The diode laser is deployed directly to the submucosal hemorrhoidal cushions in LHP. It causes photocoagulation and thus retraction of the hemorrhoidal cushions. Because of its precision and small filed of power (1mm diameter around the point of application) the risk of damage to deeper structures is minimal [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Thermal energy causes thrombosis of the venous plexus and obliteration the hemorrhoidal cushions, with adherence of the rectal mucosa and submucosal layers muscular layers. The result would be fibrosis and tissue remodelling during the healing process that would eventually cause reduction in the volume and obliteration of the hemorrhoidal tissues.\u003c/p\u003e \u003cp\u003eIn the short-term, LHP is known to be highly effective in terms of symptoms relief and reduction of prolapsed haemorrhoids. In our cohort, the procedure was well tolerated with low pain score on the VAS, consequently patients\u0026rsquo; satisfaction was described as high in 81% of the patients. This finding obviously replicates the growing literature evidence that LHP causes minimal pain and is met with high satisfaction in the short to medium-term.\u003c/p\u003e \u003cp\u003eMoreover, return to normal activities was reasonably quick and nearly all our patients returned to normal activities in the first few days after the procedure. Similar findings have been reported in previous studies, underscoring the value of non-excisional techniques for the management of hemorrhoidal disease [12\u0026amp;13]. In contrast, excisional procedures are frequently associated with delayed recovery due to postoperative pain, discharge, and wound-related symptoms.\u003c/p\u003e \u003cp\u003eSymptoms\u0026rsquo; recurrence occurred in 17 patients (22.1%) in the form of bleeding, discharge or persistent swelling. In one third of these patients, the symptoms persisted to become a florid recurrence of a clinically evident hemorrhoidal disease over time (6\u0026ndash;12 months). This symptom recurrence rate was not far from what was described by Wee et al in their systematic review as 28.6% symptoms recurrence rate [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Their review involved only patients with grade 2 or 3 haemorrhoids. The finding that over 75% of the patients had complete resolution of symptoms and suffered no recurrence of symptoms in a cohort where 83% of the patients had and advanced disease presenting as grade 3 to 4 piles adds further prove to the efficacy of LHP.\u003c/p\u003e \u003cp\u003eBleeding was the most common symptom among patients with recurrence of symptoms, accounting for approximately half of cases. In four patients, bleeding persisted beyond two months and was subsequently associated with confirmed disease recurrence. Brusciano et al described post defecatory bleeding after the procedure in up to 60% of their patients following LHP, however, this was limited to the first postoperative week and did not require intervention [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Together with our findings, this supports the coagulative and haemostatic properties of LHP.\u003c/p\u003e \u003cp\u003eWe quoted one complication that needed taking the patient back to theatres and that was a patient who developed a small submucous abscess on day 3 post-procedure. This was diagnosed by pelvic MRI and managed successfully with incision and drainage. Bleeding remains the most frequently reported complication following LHP in the literature [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Longchamp et al quoted in their systematic review an overall rate of complications post-LHP to be 64%. however, the majority were minor, with only 0.9% requiring reintervention that needed return to theatres [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the literature, reported complication rates vary widely, ranging from 10% to 42%, largely due to heterogeneity in definitions [16\u0026amp;17]. This discrepancy is mostly to do with the way authors refer to what is a complication, as many authors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] regarded symptoms\u0026rsquo; recurrence and recurrence of the disease as complications. On the other hand, others differentiate between the recurrence of symptoms and the true complications as bleeding, abscess formation and sphincter disturbance. Faes et al., in one of the larger long-term studies, reported an 18% complication rate at five years of follow-up [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our cohort, the recurrence rate at one year was 9.1%, which aligns with the findings of Longchamp et al., who reported one-year recurrence rates ranging from 0% to 11.3% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the encouraging results of LHP there yet to be a consensus on the optimum operative parameters for the procedure. Like the amount of energy to be used (more or less than 500 J per column) and the different entry points (skin Vs haemorrhoids) [19\u0026amp;20]. In our study the mean total energy delivered per patient was 1032 J with an average number of treated columns of 3 columns. This makes the average amount of energy per column around 300 to 350 J. No direct complication was ascribed to this amount of energy used in our cohort.\u003c/p\u003e \u003cp\u003eOur study is met with several limitations that made it not suitable for drawing conclusions around LHP. It is a single centre experience with a relatively small sample size. The follow up period is only for 2 years. We didn\u0026rsquo;t compare the procedure to any of the none-excisional procedures in use. Though we feel it\u0026rsquo;s an important addition to the growing number of studies assessing the outcomes of use of LHP. We quoted the outcomes in a cohort dominated by patients with advanced disease (grade 3 and 4 haemorrhoids) whereas most of the studies reported outcomes for patients with grade 2 to 3 haemorrhoids. We feel this study adds meaningful evidence to the growing literature supporting LHP. and emphasizes the need for larger, comparative, long-term studies to better define its role among non-conventional hemorrhoidal treatments.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLHP demonstrated favourable outcomes with low postoperative pain levels, minimal opioid requirements, and short hospital stays, reflecting good patient tolerance and comfort. It revealed a very low postoperative complication rate with a high degree of patient satisfaction. While recurrence of symptoms was observed in 22.1% of cases, true recurrence; defined as persistent symptoms beyond six months was limited to 9.1%. These findings support the procedure\u0026rsquo;s safety, efficacy, and positive impact on patient recovery and quality of life. However, larger scale randomized clinical trials are still required to validate our findings.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics:\u003c/strong\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Review Board of Al Salam Hospitals. \u003cstrong\u003eConsent to participate:\u003c/strong\u003e Due to the retrospective data collection of this study, the informed consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRiss S, Weiser FA, Schwameis K, Riss T, Mittlb\u0026ouml;ck M, Steiner G, Stift A (2012) The prevalence of hemorrhoids in adults. International journal of colorectal disease. 2012;27:215\u0026thinsp;\u0026ndash;\u0026thinsp;20\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Sabah S et al (2020) Results from the first Kuwait National Bariatric Surgery. 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Int J Colorectal Dis 35(3):481\u0026ndash;490. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00384-019-03460-6\u003c/span\u003e\u003cspan address=\"10.1007/s00384-019-03460-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are 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":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"lasers-in-medical-science","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"lims","sideBox":"Learn more about [Lasers in Medical Science](https://link.springer.com/journal/10103)","snPcode":"10103","submissionUrl":"https://submission.springernature.com/new-submission/10103/3","title":"Lasers in Medical Science","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Laser hemorrhoidoplasty, hemorrhoids, Pain score, minimally invasive hemorrhoidectomy","lastPublishedDoi":"10.21203/rs.3.rs-8931307/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8931307/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e This study aimed at analysing the outcomes of laser hemorrhoidoplasty (LHP) in a 2-year period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e LHP was carried out in 77 patients (83% of them had grade III or grade IV) treated over a two-year period. Inclusion criteria were an age above 18 years old, symptomatic haemorrhoids of grade 2 to 4 with minimal to moderate prolapse. Post operative pain, recurrence of the disease, recurrence of symptoms, complications, length of stay and patients’ satisfaction were all documented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe procedure was found to be safe, well tolerated, and associated with commending short to medium-term outcomes. Over 90% of patients achieved complete and sustained symptom resolution over a period of 1 year follow up despite the predominance of advanced disease in this group of patients. Disease recurrence occurred in 9.1% of the patients, postoperative pain was minimal, with a low mean pain score and limited use of opioids. Hospital stay was 1 day in most patients, and most patients returned to normal activities within the first postoperative week. 81% of the patients were highly satisfied, and 90% of patients reporting satisfactory outcomes.\u003c/p\u003e\n\u003cp\u003ePostoperative complications occurred in an only one patient who had a submucosal abscess that required surgical intervention. Regression analysis showed no association between hemorrhoidal grade, symptom duration, and postoperative complications or recurrence rate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Those outcomes support LHP as a durable minimally invasive procedure in the short to medium term. It is found to be an effective treatment option, even in patients with advanced hemorrhoidal disease.\u003c/p\u003e","manuscriptTitle":"Laser Hemorrhoidoplasty: Two-Year outcomes from a Prospective Observational Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 15:20:56","doi":"10.21203/rs.3.rs-8931307/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-11T02:46:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T19:38:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7475227579518655756613421005256531424","date":"2026-03-30T19:28:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-09T16:46:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-08T16:07:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-06T05:23:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Lasers in Medical Science","date":"2026-02-21T07:00:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"lasers-in-medical-science","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"lims","sideBox":"Learn more about [Lasers in Medical Science](https://link.springer.com/journal/10103)","snPcode":"10103","submissionUrl":"https://submission.springernature.com/new-submission/10103/3","title":"Lasers in Medical Science","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"05d389fa-3c57-45e9-a456-500a66c5dde8","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T15:53:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 15:20:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8931307","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8931307","identity":"rs-8931307","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}