Does laser treatment affect outcome in pilonidal disease? Long-term multicenter retrospective analysis of pit-picking alone vs. pit-picking with laser

Does laser treatment affect outcome in pilonidal disease? 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Long-term multicenter retrospective analysis of pit-picking alone vs. pit-picking with laser Cigdem Arslan, Ismail Ahmet Bilgin, Baris Gulcu, Baris Bayraktar, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7906871/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Objectives: The optimal management of pilonidal disease (PD) remains controversial, with multiple treatment approaches available. Pit-picking is a minimally invasive technic, often enhanced with laser treatment (LT), but the long-term benefits of LT remain uncertain. The objective of this study is to compare pit-picking alone versus pit-picking combined with LT. Methods: This is a multicenter retrospective cohort study including 7 centers across Türkiye. Patients who underwent pit-picking surgery for PD between June 2017 and March 2025 were included. Patients with adjunctive treatments beyond LT, excisional procedures, or incomplete follow-up data were excluded. Pit-picking surgery performed with or without LT were compared. The primary measure was recurrence rates at five years. Secondary outcomes were postoperative pain, time to complete healing, complications, return to work, and costs. Results: Of 306 patients, 109 (35.6%) underwent pit-picking alone, and 197 (64.4%) received pit-picking with LT. The complication rate was lower in the LT group (6.1% vs. 14.7%). Patients treated with LT had shorter times to pain-free sitting (median 5 vs. 7 days) and return to work (3 vs. 6 days). Complete healing was achieved in 97.4% of patients within a median of 14 days. Recurrence rates at five years were similar (pit-picking: 13.8%, pit-picking + LT: 12.7%). Costs were higher for the LT group ($1212±146 vs. $888±148), though complicated pit-picking cases had comparable costs to the LT group ($1198±370. Risk factors for recurrence included high BMI, family history, advanced Tezel stage, and postoperative complications. Conclusions While LT improves early postoperative outcomes, it does not impact long-term recurrence rates. The increased cost of LT should be weighed against its benefits in reducing complications, pain, and recovery time. Further randomized trials are needed to refine patient selection criteria and assess cost-effectiveness. Pilonidal disease laser treatment recurrence Figures Figure 1 Figure 2 Introduction The optimal management of pilonidal disease (PD) remains controversial, with numerous surgical and conservative treatment modalities currently available. Although surgical excision is widely accepted as the standard approach for chronic PD 1,2 there is a growing demand among both surgeons and patients for outpatient-based treatments. Since Bascom 3 introduced the cleft lift technic, minimally invasive approaches have evolved, incorporating slight modifications of pit-picking 4 . The core principle of pit-picking and its variations are excision or curettage of diseased tissue and debris through very limited incisions, preserving as much healthy skin as possible. Advancements including laser and endoscopic technologies, along with adjunctive applications like phenol and fibrin glue, have been integrated into this procedure to further enhance clinical outcomes 5 – 7 . The majority of outcomes related to pit-picking are typically based on procedures where it is combined with other approaches. A few studies for pit-picking alone revealed recurrence rates between 10–51% within 12–83 months follow-up 8,9 . Recently, laser treatment (LT) has been proposed as an adjunctive to pit-picking, offering reduced bleeding, low postoperative pain, and improved wound healing. In a review, primary healing after LT has been reported 94.4% and pooled recurrence rate at median 12 (7–25) months was found 3.8% 5 . However, existing studies are limited by short follow-up durations, and it remains uncertain whether the observed clinical effectiveness comes primarily from the addition of LT or from the pit-picking itself 10 . To address these issues, we carried out a retrospective single-center audit in 2023 and published the 36-month recurrence rates for pit-picking and LT 11 . We observed that combining LT with pit-picking positively influenced early postoperative outcome; however, no significant impact on recurrence rates was identified. Consequently, the current multicenter study was planned with a larger cohort. The primary aim of this study is to compare pit-picking and pit-picking combined with LT regarding early postoperative outcome, long-term recurrence and costs. Methods This multicenter retrospective study analyzed patients who underwent pit-picking surgery at seven high-volume centers across Türkiye. The study received ethical approval from the Istanbul Medipol University Ethics Committee (Approval no. E-10840098-772.02-2926). The pilot audit study 11 had been registered on clinicaltrials.gov (ID: NCT05569135). Due to its retrospective design, individual informed consent was not required; however, all patients had previously provided surgical consent, which included permission for the anonymized use of their recorded data in scientific research. This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Patients Data of the patients who underwent surgery for PD between June 2017 and March 2025 were reviewed. The inclusion criteria were patients older than 18 years old having pit-picking operation with or without addition of LT. Exclusion criteria included any adjunct methods to pit-picking other than LT (e.g., EPSIT, phenol, fibrin glue) as well as excisional procedures, incision and lay-open technics. The disease was classified according to the Tezel classification (Fig. 1 ) 12 . Patients with asymptomatic pits (Tezel I) and acute abscesses (Tezel II) were excluded. Hospital electronic records, nurse observations sheets and outpatient clinic archives were reviewed. Patients without complete data on the primary outcome (five-year recurrence) and key secondary outcomes (early complications, return to work, and time to complete healing) were excluded from the analysis. However, patients with missing data on day-to-painless sitting and visual analog scale (VAS) scores were not excluded; these analyses were performed within the subgroup of patients with available data. Tezel II patients have been included in the analysis if they underwent definitive pit-picking at least 2 weeks after abscess drainage and at least 1 week after cessation of antibiotics. The perioperative and postoperative follow-up data of the patients were recorded, and patients were enrolled into pit-picking alone and pit-picking with LT. The primary outcome was comparing recurrence rate at 5 year between two groups. Secondary measures were postoperative complications, time to return to work, time to complete healing and costs. Surgical Technic The LT has been first introduced in the participating centers between 2013–2018. The principal investigator (CA) has joint PD procedures with all participating centers during several professional meetings and workshops, and there is consensus among these centers regarding the standardization of the surgical technic. The decision to use LT was based on the surgeon’s or patient’s preference and, in some cases, influenced by reimbursement policies, without specific selection criteria. The procedures were performed under general, regional or local anesthesia (with or without sedation) by methods described before 11 , 13 , 14 . Patients were positioned in the prone position. Sinus openings were identified, and depending on the extent and number of tracts, 1–3 sinuses were enlarged using a scalpel, a clamp or a punch biopsy needle. Hair and necrotic tissue were removed using a clamp, curette, or brush. The cavity was irrigated with saline. For patients undergoing LT treatment, a radial laser probe (NeoV® laser, G.N.S neolaser Ltd, Regus, Israel or Ceralas® or Leonardo Dual 45® Biolitec Biomedical Technology GmbH, Jena, Germany) with a wavelength of 1470 nm was introduced through the pits and used in continuous or pulse mode at 10–15 W, with a total of 80–110 joules administered per 1 cm of the tract while the probe was gradually retracted. All lateral extensions and sinus tracts were treated. In both groups, gauze dressing was applied postoperatively. No additional wound care was recommended except for daily showering. Majority of the patients were discharged on the same day, but some who underwent general anesthesia stayed overnight. Postoperative Follow-up Patients were discharged with no restriction on sitting and showering immediately after surgery. Follow-up assessments were scheduled at postoperative days 3 and 10, and at 1, 6, and 12 months. Recurrence was evaluated via telephone interviews on 24, 36 and 60 months. Patients were provided with a VAS form to assess pain levels on postoperative days 1, 7, 10 and 30. The same form was used to record the time to painless sitting. Patients who reported recurrent symptoms during phone interviews were invited for an in-person evaluation to confirm recurrence. Since treatment was not recommended for asymptomatic cases, recurrence was defined based on patient-reported symptoms. Seroma was classified as fluid accumulation within subcutaneous tissue without signs of infection, whereas hematoma was defined as blood or clot accumulation within the subcutaneous layer. Surgical site infection was diagnosed based on purulent drainage or wound dehiscence associated with at least one of the following symptoms: pain, tenderness, erythema, swelling, or localized warmth, with or without positive culture results 15 . The time to resume daily activities was recorded as the number of days until return to work, and the time to achieve painless sitting was documented separately. Complete healing was defined as full epithelialization of the pits without spontaneous or provoked discharge. Cases where symptoms persisted beyond 2 months postoperatively were categorized as non-healing. Recurrence was defined as the reappearance of symptoms after documented complete healing. However, during recurrence analyses, non-healing patients were included in the recurrence group as this was a small group and all these individuals underwent subsequent surgical interventions. Time to recurrence was recorded as 2 months for this patients. Cost analysis Due to variations in insurance reimbursement rates among the seven centers, including all centers in our cost analysis would not have accurately determined the actual situation. Therefore, the cost analysis was made for patients reflecting the most common practice nationwide - patients receive treatment at private hospitals, covered by public social security, and pay an additional co-payment. Consequently, 133 patients from Istanbul Medipol University were included. All these patients underwent office-based procedures under local anesthesia without sedation. Total hospital costs included procedure-related charges (office use, local anesthetics, disposable equipment, laser) and 60 days follow-up related charges (office visits, wound care, seroma aspirations, cauterization etc.). Costs were expressed in US dollars, and due to fluctuations in exchange rates, each patient's expenses were calculated and recorded based on the Turkish lira to US dollar exchange rate on the date the expense was incurred. Statistical Analysis Data analysis was conducted using IBM SPSS for Windows v.26. Categorical variables were presented as frequency (n) and percentage (%) and compared using the Chi-square test or Fisher’s exact test, as appropriate. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed variables were expressed as mean ± standard deviation and compared using the Independent Samples t-test. Non-normally distributed variables were reported as median (range) and analyzed using the Mann-Whitney U test. A p-value < 0.05 was considered statistically significant. Use of Artificial Intelligence We used Microsoft co-pilot for grammar and spell-checking. Results Between 2017–2025, 4594 records have been reviewed (Fig. 2 ). A total of 306 patients were included in the analysis, of whom 109 (35.6%) underwent pit picking alone, while 197 (64.4%) received pit picking combined with LT. The distribution of the patients among institutions is given in Table 1 . Table 1 Distribution of surgeries reviewed between 2017 and 2025 across centers and patients included in the final analysis. Institution Excisional surgery Pit-picking & variations Total Included in the study Istanbul Medipol University 65 372 437 156 Acibadem University 270 161 431 69 Medicana Bursa Hospital 213 1807 2020 33 Medical Park Gebze Hospital 660 180 840 33 Cukurova University 334 90 424 13 Dokuz Eylul University Hospital 210 152 362 9 Memorial Sisli Hospital 25 55 80 2 Overall 1777 2817 4594 306 Clinical characteristics The median age was 24 (18–54), 193 (63.1%) patients were male and 113 (36.9%) were female. Male patients were significantly more likely to receive combined treatment (68.9%) compared to females (56.6%, p = 0.021). The groups were similar regarding age, BMI, symptom duration and abscess history (Table 2 ). Forty-four (14.4%) patients had Tezel V (recurrent) PD. Recurrent presentation was more common in pit-picking + LT group (18.3%) when compared to pit-picking group (7.3%) (p < 0.001) (Table 2 ). Table 2 Demographic and clinical characteristics of patients. Total (n = 306) Pit picking (n = 109, 35.6%) Pit picking + LT (n = 197, 64.4%) p Age (years, median, range) 24 (18–54) 25 (18–49) 24 (18–54) 0.507 Sex 0.021 Female 113 (36.9) 49 (43.4) 64 (56.6) Male 193 (63.1) 60 (31.1) 133 (68.9) Family history (+) 41 (13.4) 18 (16.5) 23 (11.7%) 0.155 BMI (kg/m 2 , mean ± SD) 26 ± 3.4 26.1 ± 3.2 25.9 ± 3.4 0.629 Duration of the symptoms (months, median, range) 8 (1-108) 10 (1-108) 7 (1–72) 0.407 History of abscess drainage 79 (25.8) 33 (30.3) 46 (23.4) 0.118 Smoking (+) 135 (44.4) 47 (43.1) 88 (45.1) 0.414 Tezel Classification < 0.001 III 183 (59.8) 59 (54.1) 124 (62.9) IV 79 (25.8) 42 (38.5) 37 (18.8) V 44 (14.4) 8 (7.3) 36 (18.3) LT: Laser treatment, SD: Standard deviation, BMI: Body mass index The majority of procedures were performed under local anesthesia (84.6%), with a significantly higher proportion in the pit picking group (96.3% vs. 78.2%,<0.001). The mean operative time was similar between groups (24.1 ± 5.7 vs. 22.9 ± 8.3 minutes, p = 0.172) (Table 3 ). Table 3 Comparison of surgical characteristics and outcomes. Total (n = 306) Pit picking (n = 109, 35.6%) Pit picking + LT (n = 197, 64.4%) p Anesthesia < 0.001 Local 259 (84.6) 105 (96.3) 154 (78.2) General 36 (11.8) 4 (3.7) 32 (16.2) Spinal 0 11 (5.6) 11 (3.6) Operative time (min, mean ± SD) 23.4 ± 7.4 24.1 ± 5.7 22.9 ± 8.3 0.172 Complications 28 (9.2) 16 (14.7) 12 (6.1) 0.012 Seroma 16 (5.2) 12 (11) 4 (2) 0.001 Bleeding 8 (2.6) 7 (6.4) 1 (0.5) 0.004 Surgical site infection 9 (2.9) 3 (2.8) 6 (3) 0.594 Time to return to work (days, median, range) 5 (0–20) 6 (3–17) 3 (0–20) < 0.001 Time to sit pain-free (days, median, range) 6 (1–17) 7 (3–17) 5 (1–17) < 0.001 Time to complete healing (days, median, range) 14 (2–60) 14 (8–30) 14 (2–60) 0.083 Pain score (VAS, median, range) 24 hours 2.5 (0–10) 3 (1–7) 2 (0–10) 0.265 7 days* 1 (0–3) 1 (0–3) 0 (0–3) < 0.001 30 days* 0 (0–1) 0 (0–1) 0 (0–1) 0.832 Follow-up (months, median, range) 68 (60–92) 65 (60–86) 70 (60–92) < 0.001 Recurrence (n,%) 40 (13.1) 15 (13.8) 25 (12.7) 0.460 Time-to-recurrence (days, median, range) 15 (1–90) 15 (2–24) 14.5 (1–90) 0.990 LT: Laser treatment SD: Standard deviation, VAS: Visual analogue scale, *analyzed for 156 patients whose data were available. Complications Overall complications were seen in 28 (9.2%) patients including 16 seroma, 8 bleeding and 9 surgical site infections which were all managed conservatively. Complication rate was higher in the pit picking group (14.7%) compared to the pit picking + LT group (6.1%, p = 0.012). Seroma formation (11% vs. 2%, p = 0.001) and bleeding was significantly more common in the pit picking group (6.4% vs. 0.5%, p = 0.004), where surgical site infection rates were similar between groups (2.8% vs 3%, p = 0.594). Workday loss, pain and complete healing The time to return to work (median 3 days vs. 6 days, p < 0.001) and time to sit pain-free (5 days vs. 7 days, p < 0.001) were significantly shorter in the pit picking + LT group. The VAS score at 24 hours was median 2.5 (0–10) and similar between groups. On day 7, the median VAS score was 0 (0–3) for pit-picking + LT group and significantly low when compared to pit-picking group (median 1, [0–3], p < 0.001) (Table 3 ). Complete healing was achieved at 97.4% of the entire series. Time to complete healing was median 14 (2–60) days and similar between groups (p = 0.083). Eight (2.6%) patients (4 in each groups) had persistent symptoms for 2 months and they were managed as recurrent patients (Table 3 ). Recurrence The median follow-up was 68 (60–92) months. Recurrence was seen in 40 (13.3%) patients. The median time to recurrence was 15 (1–90) months. Recurrence rates at 5 years were similar between the two groups (pit-picking 13.8% vs. pit-picking + LT 12.7%, p = 0.460) (Table 3 ). Patients with a family history of PD had a recurrence rate of 32.5%, which was significantly higher compared to those without a family history (10.5%, p = 0.001). The mean BMI (28.2 in recurrent vs. 25.5 in non-recurrent patients, p < 0.001), Tezel classification (p < 0.001) and complications were other associated factors with recurrence. Recurrence rates for Tezel III, IV and V patients were 5.5%, 16.5% and 38.6%, respectively. Patients who had postoperative complications (25%) were more likely to have recurrence when compared to those who did not have (6.8%) (p = 0.001) (Table 4 ). Table 4 The comparison of demographic and clinical characteristics between patients with and without recurrence at five years. Recurrence (-) (n = 266) Recurrence (+) (n = 40) p Age (years, median, range) 24 (18–54) 25 (18–47) 0.559 Sex 0.395 Female 97 (85.8) 16 (14.2) Male 169 (87.6) 24 (12.4) BMI (kg/m 2 , median, range) 25.5 (17.5–37.1) 28.2 (23-37.1) < 0.001 Family history (+) 13 (32.5) 28 (10.5) 0.001 Duration of the symptoms (months, median, range) 8 (1–72) 10 (2-108) 0.582 History of abscess drainage (+) 67 (84.8) 12 (15.2) 0.318 Smoking (+) 121 (89.6) 14 (10.4) 0.132 Tezel Classification < 0.001 III 172 (94.5) 10 (5.5) IV 66 (83.5) 13 (16.5) V 27 (61.4) 17 (38.6) Overall complications (+) 18 (6.8) 10 (25) 0.001 Cost analysis The total hospital costs were significantly higher in the pit-picking + LT group compared to the pit-picking group ( $ 1212 ± 146 vs. $ 888 ± 148, p = 0.004). Among these 133 patients, 10 experienced postoperative complications, including 7 cases of seroma and 3 cases of abscess, all of which occurred in the pit-picking group. Seromas were managed through repeated aspirations until complete healing, while abscesses were drained in the office setting. These patients required an average of 5.5 ± 3.2 outpatient office visits. When all costs—those related to office visits, wound care, and seroma aspirations—were included, the mean cost for patients with complications increased to $ 1198 ± 370 (Table 5 ). Table 5 Total hospital costs including procedure-related and 60 days follow-up related charges. The cost-analysis was conducted in a subgroup of 133 patients operated under local anesthesia and discharged on the same day at the same center representing similar insurance and reimbursement policies. n = 133* Pit picking (n = 80) Pit picking + LT (n = 53) p Total costs (USD, mean ± SD) 888 ± 148 1212 ± 146 0.004 Patients with complication 1198 ± 370, n = 10 n = 0 Patients without complication 818 ± 115, n = 70 1212 ± 146 < 0.001 SD: Standard deviation, LT: Laser treatment, *Patients from Istanbul Medipol University Discussion Our findings indicate that the addition of LT to pit-picking does not significantly impact long-term recurrence rates. However, the LT group had lower postoperative complications, less pain on day 7, achieved pain-free sitting earlier and returned to work earlier. Factors contributing to recurrence were high BMI, family history, advanced Tezel stage, and postoperative complications. Despite the evident early clinical benefits, the costs were significantly higher in LT group. Moreover, we observed that whether combined with LT or not, pit-picking has comparable long term recurrence rates with excisional methods 16 . Excisional surgery remains the standard treatment, with reported five-year recurrence rates of approximately 10% for off-midline techniques 1 , 2 , 17 which was comparable with our results. The five-year recurrence rate of 13.1% with pit-picking was not affected by the addition of LT in our series. Factors associated with recurrence after PD surgery are not well established. While some studies have shown that BMI is associated with higher recurrence rates 18 , 19 , others have suggested the opposite 16 . Young age, family history, hair structure, bathing habits, smoking, duration of the symptoms, history of abscess drainage, prolonged sitting, and deep natal cleft are other proposed factors, however the results remain contradictory and do not report high-quality evidence 19 – 22 . Since our data was lacking on factors potentially influencing recurrence, including hair structure, personal hygiene, perioperative hair removal, and perioperative antibiotic prophylaxis, we did not perform a multivariable analysis. However, based on the available data, recurrence was more frequent in patients with high BMI, family history, and those with more severe disease in our series. Minimally invasive treatments are recommended for mild cases in guidelines and consensus reports 23 – 26 . In line with this, our study found recurrence rates of 5.5% for Tezel III, 16.5% for Tezel IV, and 38.6% for Tezel V patients. Although our results do not demonstrate highly favorable outcomes for LT in recurrent (Tezel V) disease, a recent meta-analysis conducted by Qin et al 10 reported a healing rate of 81.9%, which decreased to 74.5% when follow-up duration exceeds 12 months. Our median follow-up was 70 months and healing rate was 61.4% in recurrent presentation. As reported in the comprehensive meta-analysis by Stauffer et al. 1 , the increase in recurrence rates with longer follow-up is an expected outcome. These results along with other literature suggest that minimally invasive methods can be a viable option in recurrent PD 6,10 . Literature on LT remains limited, but a recent review including 971 patients who underwent LT reported a recurrence rate of 3.8% with a median follow-up of 12 months 5 . The effect of LT when added to pit-picking was not evaluated before, however, Qin et. al 10 reported the outcome of 2 studies reporting LT without pit-picking and they concluded that the combination of pit-picking with LT did not affect recurrence rates. The complication rates after LT have been reported in two relatively large studies. De Decker 27 reported 8% wound infection and mean 41 days to complete healing, where Georgiou 28 reported a 10.4% complication rate with mean 4.5 days of return to activity. In our series, patients in the LT group experienced more than a twofold reduction in complication rates (6.1% vs. 14.7%) and a shorter time to return to work (3 days vs. 6 days). Moreover, a greater proportion of patients in the LT group were male and classified as Tezel V, both of which can be considered factors that increase susceptibility to complications. In our cost analysis, we found that the cost for patients with complications in the pit-picking group was similar to patients in LT group. Unfortunately, our cost analysis does not account for workforce loss or the societal burden. When considering the cost of LT, the potential cost benefits of early return to work and the postoperative comfort it provides should be taken into account. Future studies should focus on evaluating the financial burden of LT and cost-effectiveness in greater detail. Limitations The most important limitation of our study was its retrospective design and small sample size. Our cohort included higher proportion of female patients (36.9%) when compared to national reports (25%) 29 , which may introduce bias. This was possibly influenced by the fact that the two operating surgeons were female. The heterogeneity in the number of patients included across centers also limits the generalizability of our results. Conclusion Pit-picking, with or without LT, is a safe and effective treatment for PD. The addition of LT does not have an impact on long-term recurrence and increases costs. However, the improved early postoperative outcomes may justify the use of LT. A thorough cost-benefit analysis should be conducted and shared with patients when considering LT. Further randomized trials are necessary to refine patient selection and treatment indications. Declarations The authors declare no conflict of interest in connection with this article. No funding was received to assist with the preparation of this manuscript. The study received ethical approval from the Istanbul Medipol University Ethics Committee (Approval no. E-10840098-772.02-2926). Clinical Trial Registration: NCT05569135, Registration date: 05.10.2022 Informed consent forms were not obtained from the patients retrospectively for this particular study. However, all surgical consent forms include statements regarding anonymized patient data will be used in scientific studies. Every human participant has provided their written consent to involve data in the manuscript. Author Contribution CA designed the study, analyzed the data and wrote the main manuscript; IAB, BG, BB, ICE, TB, YY prepared the tables and figures, IAB, BG, BB, ICE, TB, YY , IA, AY, NR, CB, AA, CIK, SB, IEB, OB contributed to data collection and analysis of the data. IEB, OB have critically reviewed the final version. All authors reviewed the manuscript. Acknowledgements We acknowledge the Turkish Society of Colon and Rectal Surgery for pioneering the establishment of the Turkish Pilonidal Disease Study Group and for their invaluable support of our research. We also extend our sincere appreciation to Ayhan Kuzu, Ercan Gedik, Ayca Gultekin, Cihangir Akyol, Abdulcabbar Kartal, Ozgen Isik, and Timuçin Erol for their contributions. 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Pilonidal Sinus Disease: An Analysis of the Factors Affecting Recurrence. Adv Skin Wound Care . 2021;34(2):81–85. doi: 10.1097/01.ASW.0000725168.11099.92 Johnson EK, Vogel JD, Cowan ML, Feingold DL, Steele SR. The American society of colon and rectal surgeons’ clinical practice guidelines for the management of pilonidal disease. Dis Colon Rectum . 2019;62(2):146–157. doi: 10.1097/DCR.0000000000001237 Ojo D, Gallo G, Kleijnen J, et al. European Society of Coloproctology guidelines for the management of pilonidal disease. Br J Surg . 2024;111(10). doi: 10.1093/bjs/znae237 Iesalnieks I, Ommer & A, Herold & A, Doll & D. German National Guideline on the management of pilonidal disease: update 2020. Published online 2060. doi: 10.1007/s00423-020-02060-1/Published Huurman EA, Galema HA, de Raaff C, Toorenvliet B, Smeenk R. Assessment of Surgical Strategies for Pilonidal Sinus Disease in the Netherlands. Cureus . Published online May 16, 2022. doi: 10.7759/cureus.25050 De Decker M, Sels T, Van Hoof S, et al. Does minimally invasive laser-assisted treatment of pilonidal sinus disease live up to its expectations: a multi-center study with 226 patients. Int J Colorectal Dis . 2023;38(1). doi: 10.1007/s00384-023-04324-w Georgiou GK. Outpatient laser treatment of primary pilonidal disease : the PiLaT technique. Tech Coloproctol . 2018;22(10):773–778. doi: 10.1007/s10151-018-1863-5 Ergenç M, Uprak TK. Gender-specific prevalence of sacrococcygeal pilonidal sinus disease in Turkey: A retrospective analysis of a large cohort. European Surgery . 2023;55(1):43–47. doi: 10.1007/s10353-022-00777-5 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Dec, 2025 Reviews received at journal 22 Nov, 2025 Reviews received at journal 17 Nov, 2025 Reviewers agreed at journal 16 Nov, 2025 Reviewers agreed at journal 14 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviewers invited by journal 11 Nov, 2025 Editor assigned by journal 02 Nov, 2025 Submission checks completed at journal 22 Oct, 2025 First submitted to journal 20 Oct, 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. 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17:52:16","extension":"html","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122459,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7906871/v1/16b06f37cc0d5345d8ed6f36.html"},{"id":96603834,"identity":"b2007d42-3c23-4b35-8fff-bd0a5dc5673f","added_by":"auto","created_at":"2025-11-24 09:11:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":293751,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the Tezel navicular area classification.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7906871/v1/e2cb81775ebe3062cd4742fa.jpg"},{"id":96604396,"identity":"0529556c-109b-4ea3-a28e-fe62ba2a6a6a","added_by":"auto","created_at":"2025-11-24 09:13:49","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":250435,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study.\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7906871/v1/e0319547c46b3961efc90896.jpeg"},{"id":96913391,"identity":"c09dc50a-a7d2-4d12-8a75-eccc86a53645","added_by":"auto","created_at":"2025-11-27 14:00:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1427666,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7906871/v1/935c2be9-6ded-463e-8f1d-2f3f17dea641.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does laser treatment affect outcome in pilonidal disease? Long-term multicenter retrospective analysis of pit-picking alone vs. pit-picking with laser","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe optimal management of pilonidal disease (PD) remains controversial, with numerous surgical and conservative treatment modalities currently available. Although surgical excision is widely accepted as the standard approach for chronic PD\u003csup\u003e1,2\u003c/sup\u003e there is a growing demand among both surgeons and patients for outpatient-based treatments.\u003c/p\u003e\u003cp\u003eSince Bascom\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e introduced the cleft lift technic, minimally invasive approaches have evolved, incorporating slight modifications of pit-picking\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The core principle of pit-picking and its variations are excision or curettage of diseased tissue and debris through very limited incisions, preserving as much healthy skin as possible. Advancements including laser and endoscopic technologies, along with adjunctive applications like phenol and fibrin glue, have been integrated into this procedure to further enhance clinical outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe majority of outcomes related to pit-picking are typically based on procedures where it is combined with other approaches. A few studies for pit-picking alone revealed recurrence rates between 10\u0026ndash;51% within 12\u0026ndash;83 months follow-up\u003csup\u003e8,9\u003c/sup\u003e. Recently, laser treatment (LT) has been proposed as an adjunctive to pit-picking, offering reduced bleeding, low postoperative pain, and improved wound healing. In a review, primary healing after LT has been reported 94.4% and pooled recurrence rate at median 12 (7\u0026ndash;25) months was found 3.8%\u003csup\u003e5\u003c/sup\u003e. However, existing studies are limited by short follow-up durations, and it remains uncertain whether the observed clinical effectiveness comes primarily from the addition of LT or from the pit-picking itself \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTo address these issues, we carried out a retrospective single-center audit in 2023 and published the 36-month recurrence rates for pit-picking and LT \u003csup\u003e11\u003c/sup\u003e. We observed that combining LT with pit-picking positively influenced early postoperative outcome; however, no significant impact on recurrence rates was identified. Consequently, the current multicenter study was planned with a larger cohort.\u003c/p\u003e\u003cp\u003eThe primary aim of this study is to compare pit-picking and pit-picking combined with LT regarding early postoperative outcome, long-term recurrence and costs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis multicenter retrospective study analyzed patients who underwent pit-picking surgery at seven high-volume centers across T\u0026uuml;rkiye. The study received ethical approval from the Istanbul Medipol University Ethics Committee (Approval no. E-10840098-772.02-2926). The pilot audit study\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e had been registered on clinicaltrials.gov (ID: NCT05569135). Due to its retrospective design, individual informed consent was not required; however, all patients had previously provided surgical consent, which included permission for the anonymized use of their recorded data in scientific research. This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u003c/h2\u003e\u003cp\u003eData of the patients who underwent surgery for PD between June 2017 and March 2025 were reviewed. The inclusion criteria were patients older than 18 years old having pit-picking operation with or without addition of LT. Exclusion criteria included any adjunct methods to pit-picking other than LT (e.g., EPSIT, phenol, fibrin glue) as well as excisional procedures, incision and lay-open technics. The disease was classified according to the Tezel classification (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Patients with asymptomatic pits (Tezel I) and acute abscesses (Tezel II) were excluded. Hospital electronic records, nurse observations sheets and outpatient clinic archives were reviewed. Patients without complete data on the primary outcome (five-year recurrence) and key secondary outcomes (early complications, return to work, and time to complete healing) were excluded from the analysis. However, patients with missing data on day-to-painless sitting and visual analog scale (VAS) scores were not excluded; these analyses were performed within the subgroup of patients with available data. Tezel II patients have been included in the analysis if they underwent definitive pit-picking at least 2 weeks after abscess drainage and at least 1 week after cessation of antibiotics.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe perioperative and postoperative follow-up data of the patients were recorded, and patients were enrolled into pit-picking alone and pit-picking with LT. The primary outcome was comparing recurrence rate at 5 year between two groups. Secondary measures were postoperative complications, time to return to work, time to complete healing and costs.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Technic\u003c/h3\u003e\n\u003cp\u003eThe LT has been first introduced in the participating centers between 2013\u0026ndash;2018. The principal investigator (CA) has joint PD procedures with all participating centers during several professional meetings and workshops, and there is consensus among these centers regarding the standardization of the surgical technic. The decision to use LT was based on the surgeon\u0026rsquo;s or patient\u0026rsquo;s preference and, in some cases, influenced by reimbursement policies, without specific selection criteria.\u003c/p\u003e\u003cp\u003eThe procedures were performed under general, regional or local anesthesia (with or without sedation) by methods described before \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Patients were positioned in the prone position. Sinus openings were identified, and depending on the extent and number of tracts, 1\u0026ndash;3 sinuses were enlarged using a scalpel, a clamp or a punch biopsy needle. Hair and necrotic tissue were removed using a clamp, curette, or brush. The cavity was irrigated with saline. For patients undergoing LT treatment, a radial laser probe (NeoV\u0026reg; laser, G.N.S neolaser Ltd, Regus, Israel or Ceralas\u0026reg; or Leonardo Dual 45\u0026reg; Biolitec Biomedical Technology GmbH, Jena, Germany) with a wavelength of 1470 nm was introduced through the pits and used in continuous or pulse mode at 10\u0026ndash;15 W, with a total of 80\u0026ndash;110 joules administered per 1 cm of the tract while the probe was gradually retracted. All lateral extensions and sinus tracts were treated. In both groups, gauze dressing was applied postoperatively. No additional wound care was recommended except for daily showering. Majority of the patients were discharged on the same day, but some who underwent general anesthesia stayed overnight.\u003c/p\u003e\n\u003ch3\u003ePostoperative Follow-up\u003c/h3\u003e\n\u003cp\u003ePatients were discharged with no restriction on sitting and showering immediately after surgery. Follow-up assessments were scheduled at postoperative days 3 and 10, and at 1, 6, and 12 months. Recurrence was evaluated via telephone interviews on 24, 36 and 60 months. Patients were provided with a VAS form to assess pain levels on postoperative days 1, 7, 10 and 30. The same form was used to record the time to painless sitting.\u003c/p\u003e\u003cp\u003ePatients who reported recurrent symptoms during phone interviews were invited for an in-person evaluation to confirm recurrence. Since treatment was not recommended for asymptomatic cases, recurrence was defined based on patient-reported symptoms. Seroma was classified as fluid accumulation within subcutaneous tissue without signs of infection, whereas hematoma was defined as blood or clot accumulation within the subcutaneous layer. Surgical site infection was diagnosed based on purulent drainage or wound dehiscence associated with at least one of the following symptoms: pain, tenderness, erythema, swelling, or localized warmth, with or without positive culture results\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. The time to resume daily activities was recorded as the number of days until return to work, and the time to achieve painless sitting was documented separately. Complete healing was defined as full epithelialization of the pits without spontaneous or provoked discharge. Cases where symptoms persisted beyond 2 months postoperatively were categorized as non-healing. Recurrence was defined as the reappearance of symptoms after documented complete healing. However, during recurrence analyses, non-healing patients were included in the recurrence group as this was a small group and all these individuals underwent subsequent surgical interventions. Time to recurrence was recorded as 2 months for this patients.\u003c/p\u003e\n\u003ch3\u003eCost analysis\u003c/h3\u003e\n\u003cp\u003eDue to variations in insurance reimbursement rates among the seven centers, including all centers in our cost analysis would not have accurately determined the actual situation. Therefore, the cost analysis was made for patients reflecting the most common practice nationwide - patients receive treatment at private hospitals, covered by public social security, and pay an additional co-payment. Consequently, 133 patients from Istanbul Medipol University were included. All these patients underwent office-based procedures under local anesthesia without sedation.\u003c/p\u003e\u003cp\u003eTotal hospital costs included procedure-related charges (office use, local anesthetics, disposable equipment, laser) and 60 days follow-up related charges (office visits, wound care, seroma aspirations, cauterization etc.). Costs were expressed in US dollars, and due to fluctuations in exchange rates, each patient's expenses were calculated and recorded based on the Turkish lira to US dollar exchange rate on the date the expense was incurred.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData analysis was conducted using IBM SPSS for Windows v.26. Categorical variables were presented as frequency (n) and percentage (%) and compared using the Chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and compared using the Independent Samples t-test. Non-normally distributed variables were reported as median (range) and analyzed using the Mann-Whitney U test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eUse of Artificial Intelligence\u003c/h2\u003e\u003cp\u003eWe used Microsoft co-pilot for grammar and spell-checking.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 2017\u0026ndash;2025, 4594 records have been reviewed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A total of 306 patients were included in the analysis, of whom 109 (35.6%) underwent pit picking alone, while 197 (64.4%) received pit picking combined with LT. The distribution of the patients among institutions is given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\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\u003eDistribution of surgeries reviewed between 2017 and 2025 across centers and patients included in the final analysis.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstitution\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExcisional\u003c/p\u003e\u003cp\u003esurgery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePit-picking \u0026amp; variations\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIncluded in the study\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIstanbul Medipol University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e437\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e156\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcibadem University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e270\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e431\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedicana Bursa Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e213\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1807\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Park Gebze Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e660\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e840\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCukurova University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e334\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e424\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDokuz Eylul University Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e362\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMemorial Sisli Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1777\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2817\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4594\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e306\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eClinical characteristics\u003c/h3\u003e\n\u003cp\u003eThe median age was 24 (18\u0026ndash;54), 193 (63.1%) patients were male and 113 (36.9%) were female. Male patients were significantly more likely to receive combined treatment (68.9%) compared to females (56.6%, p\u0026thinsp;=\u0026thinsp;0.021). The groups were similar regarding age, BMI, symptom duration and abscess history (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Forty-four (14.4%) patients had Tezel V (recurrent) PD. Recurrent presentation was more common in pit-picking\u0026thinsp;+\u0026thinsp;LT group (18.3%) when compared to pit-picking group (7.3%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and clinical characteristics of patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePit picking\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;109, 35.6%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePit picking\u0026thinsp;+\u0026thinsp;LT\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;197, 64.4%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (18\u0026ndash;54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (18\u0026ndash;49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (18\u0026ndash;54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.507\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\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\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e113 (36.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (43.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64 (56.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e193 (63.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (31.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e133 (68.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily history (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (13.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (11.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.155\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.629\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of the symptoms (months, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (1-108)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (1-108)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (1\u0026ndash;72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.407\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of abscess drainage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (25.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (30.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46 (23.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.118\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e135 (44.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88 (45.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.414\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTezel Classification\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\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e183 (59.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (54.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e124 (62.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (25.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (38.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37 (18.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (14.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 (18.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eLT: Laser treatment, SD: Standard deviation, BMI: Body mass index\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe majority of procedures were performed under local anesthesia (84.6%), with a significantly higher proportion in the pit picking group (96.3% vs. 78.2%,\u0026lt;0.001). The mean operative time was similar between groups (24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 vs. 22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 minutes, p\u0026thinsp;=\u0026thinsp;0.172) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of surgical characteristics and outcomes.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;306)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePit picking\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;109, 35.6%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePit picking\u0026thinsp;+\u0026thinsp;LT\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;197, 64.4%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnesthesia\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\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e259 (84.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105 (96.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e154 (78.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\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\u003e36 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 (16.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpinal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (3.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time (min, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.172\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeroma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (5.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBleeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical site infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.594\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime to return to work (days, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (0\u0026ndash;20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (3\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (0\u0026ndash;20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime to sit pain-free (days, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (1\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (3\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (1\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime to complete healing (days, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (2\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (8\u0026ndash;30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (2\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain score (VAS, median, range)\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.5 (0\u0026ndash;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (1\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (0\u0026ndash;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.265\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7 days*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30 days*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.832\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up (months, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68 (60\u0026ndash;92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65 (60\u0026ndash;86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70 (60\u0026ndash;92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecurrence (n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (13.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (13.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (12.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.460\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime-to-recurrence (days, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (1\u0026ndash;90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (2\u0026ndash;24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.5 (1\u0026ndash;90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.990\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eLT: Laser treatment SD: Standard deviation, VAS: Visual analogue scale, *analyzed for 156 patients whose data were available.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eComplications\u003c/h2\u003e\u003cp\u003eOverall complications were seen in 28 (9.2%) patients including 16 seroma, 8 bleeding and 9 surgical site infections which were all managed conservatively. Complication rate was higher in the pit picking group (14.7%) compared to the pit picking\u0026thinsp;+\u0026thinsp;LT group (6.1%, p\u0026thinsp;=\u0026thinsp;0.012). Seroma formation (11% vs. 2%, p\u0026thinsp;=\u0026thinsp;0.001) and bleeding was significantly more common in the pit picking group (6.4% vs. 0.5%, p\u0026thinsp;=\u0026thinsp;0.004), where surgical site infection rates were similar between groups (2.8% vs 3%, p\u0026thinsp;=\u0026thinsp;0.594).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eWorkday loss, pain and complete healing\u003c/h2\u003e\u003cp\u003eThe time to return to work (median 3 days vs. 6 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and time to sit pain-free (5 days vs. 7 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly shorter in the pit picking\u0026thinsp;+\u0026thinsp;LT group. The VAS score at 24 hours was median 2.5 (0\u0026ndash;10) and similar between groups. On day 7, the median VAS score was 0 (0\u0026ndash;3) for pit-picking\u0026thinsp;+\u0026thinsp;LT group and significantly low when compared to pit-picking group (median 1, [0\u0026ndash;3], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eComplete healing was achieved at 97.4% of the entire series. Time to complete healing was median 14 (2\u0026ndash;60) days and similar between groups (p\u0026thinsp;=\u0026thinsp;0.083). Eight (2.6%) patients (4 in each groups) had persistent symptoms for 2 months and they were managed as recurrent patients (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eRecurrence\u003c/h2\u003e\u003cp\u003eThe median follow-up was 68 (60\u0026ndash;92) months. Recurrence was seen in 40 (13.3%) patients. The median time to recurrence was 15 (1\u0026ndash;90) months. Recurrence rates at 5 years were similar between the two groups (pit-picking 13.8% vs. pit-picking\u0026thinsp;+\u0026thinsp;LT 12.7%, p\u0026thinsp;=\u0026thinsp;0.460) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Patients with a family history of PD had a recurrence rate of 32.5%, which was significantly higher compared to those without a family history (10.5%, p\u0026thinsp;=\u0026thinsp;0.001). The mean BMI (28.2 in recurrent vs. 25.5 in non-recurrent patients, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Tezel classification (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and complications were other associated factors with recurrence. Recurrence rates for Tezel III, IV and V patients were 5.5%, 16.5% and 38.6%, respectively. Patients who had postoperative complications (25%) were more likely to have recurrence when compared to those who did not have (6.8%) (p\u0026thinsp;=\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe comparison of demographic and clinical characteristics between patients with and without recurrence at five years.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecurrence (-)\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;266)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRecurrence (+) (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (18\u0026ndash;54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (18\u0026ndash;47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.559\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\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=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.395\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e97 (85.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (14.2)\u003c/p\u003e\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\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e169 (87.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (12.4)\u003c/p\u003e\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\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.5 (17.5\u0026ndash;37.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.2 (23-37.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily history (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (32.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of the symptoms (months, median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (1\u0026ndash;72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (2-108)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.582\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of abscess drainage (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67 (84.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.318\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121 (89.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTezel Classification\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=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e172 (94.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (5.5)\u003c/p\u003e\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\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66 (83.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (16.5)\u003c/p\u003e\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\u003eV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (61.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (38.6)\u003c/p\u003e\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\u003eOverall complications (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eCost analysis\u003c/h2\u003e\u003cp\u003eThe total hospital costs were significantly higher in the pit-picking\u0026thinsp;+\u0026thinsp;LT group compared to the pit-picking group (\u003cspan\u003e$\u003c/span\u003e1212\u0026thinsp;\u0026plusmn;\u0026thinsp;146 vs. \u003cspan\u003e$\u003c/span\u003e888\u0026thinsp;\u0026plusmn;\u0026thinsp;148, p\u0026thinsp;=\u0026thinsp;0.004). Among these 133 patients, 10 experienced postoperative complications, including 7 cases of seroma and 3 cases of abscess, all of which occurred in the pit-picking group. Seromas were managed through repeated aspirations until complete healing, while abscesses were drained in the office setting. These patients required an average of 5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 outpatient office visits. When all costs\u0026mdash;those related to office visits, wound care, and seroma aspirations\u0026mdash;were included, the mean cost for patients with complications increased to \u003cspan\u003e$\u003c/span\u003e1198\u0026thinsp;\u0026plusmn;\u0026thinsp;370 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTotal hospital costs including procedure-related and 60 days follow-up related charges. The cost-analysis was conducted in a subgroup of 133 patients operated under local anesthesia and discharged on the same day at the same center representing similar insurance and reimbursement policies.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;133*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePit picking\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePit picking\u0026thinsp;+\u0026thinsp;LT (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal costs (USD, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e888\u0026thinsp;\u0026plusmn;\u0026thinsp;148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1212\u0026thinsp;\u0026plusmn;\u0026thinsp;146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients with complication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1198\u0026thinsp;\u0026plusmn;\u0026thinsp;370, n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\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\u003ePatients without complication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e818\u0026thinsp;\u0026plusmn;\u0026thinsp;115, n\u0026thinsp;=\u0026thinsp;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1212\u0026thinsp;\u0026plusmn;\u0026thinsp;146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD: Standard deviation, LT: Laser treatment, *Patients from Istanbul Medipol University\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings indicate that the addition of LT to pit-picking does not significantly impact long-term recurrence rates. However, the LT group had lower postoperative complications, less pain on day 7, achieved pain-free sitting earlier and returned to work earlier. Factors contributing to recurrence were high BMI, family history, advanced Tezel stage, and postoperative complications. Despite the evident early clinical benefits, the costs were significantly higher in LT group. Moreover, we observed that whether combined with LT or not, pit-picking has comparable long term recurrence rates with excisional methods\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eExcisional surgery remains the standard treatment, with reported five-year recurrence rates of approximately 10% for off-midline techniques\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e which was comparable with our results. The five-year recurrence rate of 13.1% with pit-picking was not affected by the addition of LT in our series. Factors associated with recurrence after PD surgery are not well established. While some studies have shown that BMI is associated with higher recurrence rates\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, others have suggested the opposite\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Young age, family history, hair structure, bathing habits, smoking, duration of the symptoms, history of abscess drainage, prolonged sitting, and deep natal cleft are other proposed factors, however the results remain contradictory and do not report high-quality evidence\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Since our data was lacking on factors potentially influencing recurrence, including hair structure, personal hygiene, perioperative hair removal, and perioperative antibiotic prophylaxis, we did not perform a multivariable analysis. However, based on the available data, recurrence was more frequent in patients with high BMI, family history, and those with more severe disease in our series.\u003c/p\u003e\u003cp\u003eMinimally invasive treatments are recommended for mild cases in guidelines and consensus reports\u003csup\u003e\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. In line with this, our study found recurrence rates of 5.5% for Tezel III, 16.5% for Tezel IV, and 38.6% for Tezel V patients. Although our results do not demonstrate highly favorable outcomes for LT in recurrent (Tezel V) disease, a recent meta-analysis conducted by Qin et al\u003csup\u003e10\u003c/sup\u003e reported a healing rate of 81.9%, which decreased to 74.5% when follow-up duration exceeds 12 months. Our median follow-up was 70 months and healing rate was 61.4% in recurrent presentation. As reported in the comprehensive meta-analysis by Stauffer et al.\u003csup\u003e1\u003c/sup\u003e, the increase in recurrence rates with longer follow-up is an expected outcome. These results along with other literature suggest that minimally invasive methods can be a viable option in recurrent PD\u003csup\u003e6,10\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eLiterature on LT remains limited, but a recent review including 971 patients who underwent LT reported a recurrence rate of 3.8% with a median follow-up of 12 months\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The effect of LT when added to pit-picking was not evaluated before, however, Qin et. al\u003csup\u003e10\u003c/sup\u003e reported the outcome of 2 studies reporting LT without pit-picking and they concluded that the combination of pit-picking with LT did not affect recurrence rates. The complication rates after LT have been reported in two relatively large studies. De Decker\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e reported 8% wound infection and mean 41 days to complete healing, where Georgiou\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e reported a 10.4% complication rate with mean 4.5 days of return to activity. In our series, patients in the LT group experienced more than a twofold reduction in complication rates (6.1% vs. 14.7%) and a shorter time to return to work (3 days vs. 6 days). Moreover, a greater proportion of patients in the LT group were male and classified as Tezel V, both of which can be considered factors that increase susceptibility to complications. In our cost analysis, we found that the cost for patients with complications in the pit-picking group was similar to patients in LT group. Unfortunately, our cost analysis does not account for workforce loss or the societal burden. When considering the cost of LT, the potential cost benefits of early return to work and the postoperative comfort it provides should be taken into account. Future studies should focus on evaluating the financial burden of LT and cost-effectiveness in greater detail.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThe most important limitation of our study was its retrospective design and small sample size. Our cohort included higher proportion of female patients (36.9%) when compared to national reports (25%)\u003csup\u003e29\u003c/sup\u003e, which may introduce bias. This was possibly influenced by the fact that the two operating surgeons were female. The heterogeneity in the number of patients included across centers also limits the generalizability of our results.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePit-picking, with or without LT, is a safe and effective treatment for PD. The addition of LT does not have an impact on long-term recurrence and increases costs. However, the improved early postoperative outcomes may justify the use of LT. A thorough cost-benefit analysis should be conducted and shared with patients when considering LT. Further randomized trials are necessary to refine patient selection and treatment indications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare no conflict of interest in connection with this article. No funding was received to assist with the preparation of this manuscript.\u003c/p\u003e\u003cp\u003eThe study received ethical approval from the Istanbul Medipol University Ethics Committee (Approval no. E-10840098-772.02-2926).\u003c/p\u003e\u003cp\u003eClinical Trial Registration: NCT05569135, Registration date: 05.10.2022\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003cp\u003eforms were not obtained from the patients retrospectively for this particular study. However, all surgical consent forms include statements regarding anonymized patient data will be used in scientific studies. Every human participant has provided their written consent to involve data in the manuscript.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCA designed the study, analyzed the data and wrote the main manuscript; IAB, BG, BB, ICE, TB, YY prepared the tables and figures, IAB, BG, BB, ICE, TB, YY , IA, AY, NR, CB, AA, CIK, SB, IEB, OB contributed to data collection and analysis of the data. IEB, OB have critically reviewed the final version. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe acknowledge the Turkish Society of Colon and Rectal Surgery for pioneering the establishment of the Turkish Pilonidal Disease Study Group and for their invaluable support of our research. We also extend our sincere appreciation to Ayhan Kuzu, Ercan Gedik, Ayca Gultekin, Cihangir Akyol, Abdulcabbar Kartal, Ozgen Isik, and Timu\u0026ccedil;in Erol for their contributions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStauffer VK, Luedi MM, Kauf P, et al. 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Gender-specific prevalence of sacrococcygeal pilonidal sinus disease in Turkey: A retrospective analysis of a large cohort. \u003cem\u003eEuropean Surgery\u003c/em\u003e. 2023;55(1):43\u0026ndash;47. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10353-022-00777-5\u003c/span\u003e\u003cspan address=\"10.1007/s10353-022-00777-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pilonidal disease, laser treatment, recurrence","lastPublishedDoi":"10.21203/rs.3.rs-7906871/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7906871/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThe optimal management of pilonidal disease (PD) remains controversial, with multiple treatment approaches available. Pit-picking is a minimally invasive technic, often enhanced with laser treatment (LT), but the long-term benefits of LT remain uncertain. The objective of this study is to compare pit-picking alone versus pit-picking combined with LT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis is a multicenter retrospective cohort study including 7 centers across Türkiye. Patients who underwent pit-picking surgery for PD between June 2017 and March 2025 were included. Patients with adjunctive treatments beyond LT, excisional procedures, or incomplete follow-up data were excluded. Pit-picking surgery performed with or without LT were compared. The primary measure was recurrence rates at five years. Secondary outcomes were postoperative pain, time to complete healing, complications, return to work, and costs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf 306 patients, 109 (35.6%) underwent pit-picking alone, and 197 (64.4%) received pit-picking with LT. The complication rate was lower in the LT group (6.1% vs. 14.7%). Patients treated with LT had shorter times to pain-free sitting (median 5 vs. 7 days) and return to work (3 vs. 6 days). Complete healing was achieved in 97.4% of patients within a median of 14 days. Recurrence rates at five years were similar (pit-picking: 13.8%, pit-picking + LT: 12.7%). Costs were higher for the LT group ($1212±146 vs. $888±148), though complicated pit-picking cases had comparable costs to\u003cstrong\u003e \u003c/strong\u003ethe LT group ($1198±370. Risk factors for recurrence\u003cstrong\u003e \u003c/strong\u003eincluded high BMI, family history, advanced Tezel stage, and postoperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003cbr\u003e\n \u003c/strong\u003eWhile LT improves early postoperative outcomes, it does not impact long-term recurrence rates. The increased cost of LT should be weighed against its benefits in reducing complications, pain, and recovery time. Further randomized trials are needed to refine patient selection criteria and assess cost-effectiveness.\u003c/p\u003e","manuscriptTitle":"Does laser treatment affect outcome in pilonidal disease? Long-term multicenter retrospective analysis of pit-picking alone vs. pit-picking with laser","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-21 17:52:11","doi":"10.21203/rs.3.rs-7906871/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-06T18:40:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-22T16:38:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-17T07:56:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21871769936769754010602859482842967533","date":"2025-11-16T16:24:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280674817017872395861660381895289862627","date":"2025-11-14T10:31:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331700904575905143626787829613271547768","date":"2025-11-11T15:35:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T13:58:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255177371280636910995481873670679173643","date":"2025-11-11T12:50:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-11T12:26:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-02T21:48:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-22T08:35:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2025-10-20T14:40:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"73affdd2-fa8c-4a51-90df-27905e4952a3","owner":[],"postedDate":"November 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-20T03:39:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-21 17:52:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7906871","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7906871","identity":"rs-7906871","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}