Excisional hemorrhoidectomy and stapled hemorrhoidopexy are 2 common procedures for treating symptomatic hemorrhoids. However, concerns persist regarding the risk of postoperative complications and their unclear prevalence in the literature. This systematic review aims to evaluate and compare the prevalence of incontinence after stapled hemorrhoidopexy and excisional hemorrhoidectomy.

A systematic search of Medline, EMBASE, and CENTRAL identified studies published in the past 25 years that reported incontinence after excisional treatments for hemorrhoids. Primary outcomes included early (<3 months) and late (≥3 months) fecal incontinence. Secondary outcomes included postoperative bleeding, urinary retention, and recurrence. Single-arm meta-analyses of proportions were performed using R with meta-regression.

In total, 139 studies were included in the meta-analysis, including 68 randomized controlled trials with 8,445 participants and 71 observational studies with 22,687 participants. Early incontinence rates were 5.32% in randomized controlled trials (95% confidence interval, 2.74-8.51%) and 1.03% in nonrandomized controlled trials (95% confidence interval, 0.28-2.09%). Late incontinence rates were 2.48% in randomized controlled trials (95% confidence interval, 1.09-4.25%) and 1.44% in nonrandomized controlled trials (95% confidence interval, 0.71-2.37%). There was no significant difference in the risk of incontinence or other postoperative complications between stapled hemorrhoidopexy and excisional hemorrhoidectomy, both in randomized controlled trials and nonrandomized controlled trials.

Incontinence after stapled hemorrhoidopexy and excisional hemorrhoidectomy is uncommon, and there appears to be no significant difference in risk between the 2 procedures. However, considerable heterogeneity was observed, likely the result of differences in assessment and reporting methods across studies. Future research should standardize definitions and methods for assessing incontinence and include preoperative assessments to more accurately define the risks of complications associated with hemorrhoid surgery.

The pathogenesis of hemorrhoids is a weakening of the anal cushion and spasm of the internal sphincter. Bowel habits and lifestyles can be risk factors for hemorrhoids. The prevalence of hemorrhoids can encompass 4 to 55% of the population. Symptoms include bleeding, pain, prolapsing, swelling, itching, and mucus soiling. The diagnosis of hemorrhoids requires taking a thorough history and conducting an anorectal examination. Goligher's classification, which indicates the degree of prolapsing with internal hemorrhoids, is useful for choosing treatment. Drug therapy for hemorrhoids is typically utilized for bleeding, pain, and swelling. Ligation and excision (LE) is considered for Grade III and IV internal and external hemorrhoids. Rubber band ligation is used to treat up to Grade III internal hemorrhoids. Phenol almond oil is effective for internal hemorrhoids up to Grade III, while aluminum potassium sulfate and tannic acid have shown efficacy in treating prolapsing in internal hemorrhoids at Grades II, III, and IV. Procedure for prolapse and hemorrhoids (PPH) is surgically effective for Grade III internal hemorrhoids; however, the long-term prognosis is not favorable, with high recurrence rates. Separating ligation is effective surgical treatment for internal/external hemorrhoids Grade III and Grade IV. The basic approach to thrombosed external hemorrhoids and incarcerated hemorrhoids is conservative treatment; however, in some acute or severe cases, surgical resection is considered. Comparing the different instruments used for hemorrhoid surgery, all reduce operating time, blood loss, post-operative pain, and length of time until the return to normal activity. They do, of course, increase the cost of the procedure.

The aim was to compare the clinical outcomes and effectiveness of surgical treatments for haemorrhoids.

Randomized clinical trials were identified by means of a systematic review. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS.

Ninety-eight trials were included with 7827 participants and 11 surgical treatments for grade III and IV haemorrhoids. Open, closed and radiofrequency haemorrhoidectomies resulted in significantly more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™ and Harmonic® haemorrhoidectomies. THD had significantly less postoperative bleeding than open and stapled procedures, and resulted in significantly fewer emergency reoperations than open, closed, stapled and LigaSure™ haemorrhoidectomies. Open and closed haemorrhoidectomies resulted in more pain on postoperative day 1 than stapled, THD, LigaSure™ and Harmonic® procedures. After stapled, LigaSure™ and Harmonic® haemorrhoidectomies patients resumed normal daily activities earlier than after open and closed procedures. THD provided the earliest time to first bowel movement. The stapled and THD groups had significantly higher haemorrhoid recurrence rates than the open, closed and LigaSure™ groups. Recurrence of haemorrhoidal symptoms was more common after stapled haemorrhoidectomy than after open and LigaSure™ operations. No significant difference was identified between treatments for anal stenosis, incontinence and perianal skin tags.

Open and closed haemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates. The advantages and disadvantages of each surgical treatment should be discussed with the patient before surgery to allow an informed decision to be made.