Radiofrequency Hemorrhoidectomy for Grade III-IV Hemorrhoids
Radiofrequency ablation with plication (RAP) is a viable alternative to conventional excisional hemorrhoidectomy for grade III hemorrhoids, offering significantly less postoperative pain, shorter hospital stays (1 vs. 3 days), and faster return to work (7 vs. 17 days), though it is not mentioned in current major guidelines and has limited long-term data. 1
Evidence Quality and Guideline Status
The American Gastroenterological Association guidelines do not include radiofrequency hemorrhoidectomy among recommended surgical options, instead listing conventional excisional hemorrhoidectomy, stapled hemorrhoidopexy, and hemorrhoidal artery ligation as the standard surgical approaches. 2 This absence from major guidelines reflects the limited evidence base compared to established techniques.
Clinical Evidence for Radiofrequency Ablation
Efficacy Data
A randomized trial of 60 patients with grade III hemorrhoids demonstrated that radiofrequency ablation with plication achieved comparable efficacy to Milligan-Morgan hemorrhoidectomy, with only one asymptomatic recurrence noted in the RAP group during 2-year follow-up. 1
A retrospective study of 240 patients with grade I-II hemorrhoids treated with radiofrequency coagulation showed that 33 patients (14%) reported persistence or recurrence of bleeding over 16 months, with few complaints of pain or discomfort. 3
Pain and Recovery Advantages
Post-defecation pain and pain at rest were significantly lower with radiofrequency ablation compared to Milligan-Morgan hemorrhoidectomy (p<0.05). 1
Wound healing occurred in 17 days with RAP versus 38 days with conventional hemorrhoidectomy, and patients returned to work in 7 days versus 17 days respectively. 1
Duration of surgery was significantly shorter with radiofrequency ablation, and postoperative hospitalization was reduced compared to conventional hemorrhoidectomy. 1
Complications Profile
Early Complications
- Early complications occurred more frequently with Milligan-Morgan hemorrhoidectomy than with radiofrequency ablation. 1
Late Complications
External skin tags developed more commonly after radiofrequency ablation (4 patients) compared to conventional hemorrhoidectomy (2 patients). 1
The low complication rate and minimal pain make radiofrequency coagulation particularly suitable for office-based treatment of grade I-II hemorrhoids. 3
Comparison with Rubber Band Ligation
A randomized blinded study demonstrated that while rubber band ligation is effective, its pain quotient is greater than radiofrequency coagulation, making RF an attractive option for patients prioritizing comfort. 3
Current Treatment Algorithm Context
When RF Might Be Considered
For grade III hemorrhoids in patients who prioritize faster recovery and less postoperative pain over the lowest possible recurrence rate. 1
For grade I-II hemorrhoids when office-based procedures like rubber band ligation (89% success rate) have failed or are not tolerated. 2, 3
When Conventional Hemorrhoidectomy Remains Superior
Conventional excisional hemorrhoidectomy remains the gold standard for grade IV hemorrhoids and mixed internal-external disease, with recurrence rates of only 2-10%. 2, 4
For grade III hemorrhoids with extensive prolapse or when lowest recurrence rate is the priority, conventional hemorrhoidectomy is still preferred despite longer recovery. 2
Critical Limitations
The evidence base consists primarily of small studies with limited long-term follow-up, which explains why radiofrequency techniques are not included in major society guidelines. 3, 1
No head-to-head comparisons exist with newer techniques like stapled hemorrhoidopexy or hemorrhoidal artery ligation that are mentioned in current guidelines. 2
The technique requires specialized equipment (Ellman radiofrequency generator) that may not be widely available. 3
Clinical Bottom Line
While radiofrequency hemorrhoidectomy shows promise for reducing postoperative pain and recovery time in grade III hemorrhoids, it should be considered an alternative rather than first-line surgical option given its absence from major guidelines and limited long-term data. 2, 1 For grade I-II disease, it represents a reasonable office-based alternative to rubber band ligation when patient comfort is prioritized. 3 However, conventional excisional hemorrhoidectomy remains the evidence-based standard for grade III-IV disease when definitive treatment with lowest recurrence is required. 2, 4, 5