Comparison of efficacy and safety of different treatment modalities for hemorrhoids: A network meta-analysis

Table 1 Characteristics of included studies

Reference	Grade of hemorrhoids	Treatment	Sample size	Recurrence	Effectiveness	Satisfaction	Further treatment	Pain	Bleeding	Urinary retention	Septic complications	Anorectal stenosis	Incontinence	Constipation
McKenzie et al[13], 2010	II	RBL vs SH	60	Reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported
Sakr[14], 2010	III/IV	MM vs LigaH	84	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Reported	Reported
Nyström et al[15], 2010	III/IV	MM vs SH	180	Not reported	Reported	Not reported	Not reported	Reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported
Abo-hashem et al[16], 2010	III/IV	HarS vs BPC	64	Not reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Reported	Not reported	Reported	Not reported
Filingeri et al[17], 2010	IV	FH vs RFC	28	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Not reported
Sakr et al[18], 2010	III/IV	SH vs LigaH	68	Reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Reported	Reported	Reported	Reported
Giordano et al[19], 2011	II/III	SH vs HAL	52	Reported	Not reported	Reported	Reported	Reported	Reported	Reported	Not reported	Reported	Reported	Not reported
Zaher et al[20], 2011	II/III/IV	SH vs RBL	26	Reported	Not reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Not reported	Reported	Not reported
Franceschilli et al[21], 2011	III/IV	MM vs LigaH	210	Reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Giamundo et al[22], 2011	II/III	HAL vs RBL	60	Not reported	Reported	Reported	Not reported	Not reported	Reported	Reported	Not reported	Not reported	Reported	Not reported
Infantino et al[23], 2012	III	SH vs HAL	169	Reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Reported	Not reported	Reported	Reported
Gupta et al[24], 2011	III	SLM vs HAL	48	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Reported	Not reported	Not reported	Not reported
Arslani et al[25], 2012	III	SH vs LigaH	98	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Not reported	Reported	Reported	Not reported
Filingeri et al[26], 2012	II	RBL vs CHR	90	Not reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported
Ammaturo et al[27], 2012	III	MM vs SH	79	Reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Reported	Not reported	Reported	Not reported
Zampieri et al[28], 2012	III/IV	HAL vs LigaH	114	Not reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Not reported	Not reported	Reported	Not reported
Elmér et al[29], 2013	II/III	MM vs HAL	40	Not reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Not reported	Reported	Reported	Not reported
Kim et al[30], 2013	III	MM vs SH	122	Reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Not reported	Not reported	Reported	Not reported
Bulus et al[31], 2014	III/IV	FH vs HarS	151	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Reported	Not reported
Verre et al[32], 2013	III/IV	HAL vs SH	122	Not reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported
Ahmad et al[33], 2013	I/II	HAL vs IRC	245	Not reported	Reported	Not reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported
Gagloo et al[34], 2013	II/III	MM vs RBL	100	Not reported	Not reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported
De Nardi et al[35], 2014	III	MM vs HAL	50	Reported	Not reported	Reported	Reported	Not reported	Reported	Not reported	Not reported	Reported	Reported	Not reported
Talha et al[36], 2017	III/IV	MM vs HarS vs LigaH	180	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Not reported	Reported	Not reported	Not reported
Denoya et al[37], 2014	III/IV	FH vs HAL	27	Reported	Reported	Not reported	Reported	Reported	Reported	Not reported	Not reported	Reported	Reported	Not reported
Elshazly et al[38], 2015	II/III	MM vs SLM	200	Reported	Not reported	Not reported	Not reported	Reported	Reported	Reported	Not reported	Not reported	Reported	Reported
Bilgin et al[39], 2015	III/IV	SH vs HarS	99	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Reported	Not reported
Wang et al[40], 2015	III/IV	MM vs TST	480	Not reported	Reported	Reported	Not reported	Reported	Not reported	Reported	Not reported	Not reported	Reported	Reported
Lu et al[41], 2015	III/IV	MM vs SH	108	Reported	Not reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Reported
Ripetti et al[42], 2015	III/IV	MM vs SCH vs SH	180	Reported	Not reported	Not reported	Not reported	Reported	Reported	Reported	Not reported	Reported	Reported	Not reported
Aigner et al[43], 2016	III	HAL vs SLM	40	Reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported
Zhai et al[44], 2016	III	HAL vs SLM	100	Reported	Reported	Reported	Reported	Not reported	Reported	Reported	Not reported	Reported	Reported	Not reported
Brown et al[45], 2016	II/III	HAL vs RBL	372	Reported	Reported	Not reported	Reported	Reported	Reported	Reported	Reported	Not reported	Not reported	Not reported
Leardi et al[46], 2016	II/III	SH vs HAL	100	Reported	Not reported	Reported	Reported	Reported	Reported	Not reported	Not reported	Not reported	Reported	Not reported
Watson et al[47], 2016	II/III/IV	MM vs SH	774	Reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Reported	Reported	Not reported	Reported
Lehur et al[48], 2016	II/III	SH vs HAL	393	Reported	Not reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Naderan et al[49], 2017	II/III	MM vs LASER	60	Reported	Reported	Not reported	Reported	Not reported	Reported	Reported	Reported	Not reported	Not reported	Not reported
Nikooiyan et al[50], 2016	I/II/III/IV	FH vs DCV	120	Reported	Reported	Not reported	Reported	Reported	Reported	Reported	Reported	Not reported	Reported	Reported
Tsunoda et al[51], 2017	III	HAL vs HarS	44	Not reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Not reported	Reported	Not reported	Not reported
Leung et al[52], 2017	II/III	HAL vs TST	80	Reported	Not reported	Not reported	Reported	Not reported	Not reported	Reported	Not reported	Reported	Not reported	Not reported
Nikshoar et al[53], 2018	III	FH vs IRC	40	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported
Giarratano et al[54], 2018	III/IV	SH vs HAL	100	Reported	Not reported	Reported	Reported	Not reported	Reported	Not reported	Not reported	Not reported	Not reported	Not reported
Venara et al[55], 2018	II/III	SH vs HAL	377	Reported	Not reported	Not reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Lisi et al[56], 2019	III/IV	LigaH vs RFC	50	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Not reported	Reported	Reported	Not reported
Carvajal López et al[57], 2019	III/IV	MM vs HAL	40	Reported	Reported	Not reported	Reported	Reported	Reported	Reported	Not reported	Not reported	Not reported	Not reported
Trenti et al[58], 2019	III/IV	LigaH vs HAL	80	Not reported	Not reported	Reported	Not reported	Not reported	Reported	Reported	Reported	Not reported	Not reported	Not reported
Genova et al[59], 2019	III/IV	MM vs HAL	89	Reported	Not reported	Not reported	Reported	Not reported	Reported	Not reported	Reported	Reported	Not reported	Not reported
Poskus et al[60], 2020	II/III	MM vs SLM vs LASER	121	Reported	Reported	Not reported	Reported	Not reported	Not reported	Not reported	Reported	Reported	Not reported	Not reported
Rørvik et al[61], 2020	II/III/IV	MM vs HAL	98	Reported	Not reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Not reported
Abiodun et al[62], 2020	II/III	IJS vs RBL	60	Reported	Reported	Reported	Reported	Reported	Reported	Not reported	Reported	Not reported	Not reported	Not reported
Jin et al[63], 2021	III	RBL vs MM	120	Reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Not reported	Not reported	Not reported	Not reported
Zhai et al[64], 2022	II/III/IV	SLM vs MM	123	Reported	Not reported	Reported	Reported	Not reported	Reported	Not reported	Not reported	Not reported	Reported	Not reported
Lee et al[65], 2021	III/IV	HAL vs LigaH	80	Not reported	Reported	Reported	Reported	Reported	Reported	Reported	Not reported	Not reported	Not reported	Not reported
Huang et al[66], 2021	III/IV	MM vs TST	169	Reported	Not reported	Reported	Not reported	Not reported	Reported	Reported	Not reported	Reported	Not reported	Not reported
Song et al[67], 2022	III/IV	MPSH vs MM	186	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Not reported	Reported	Not reported	Not reported
Salgueiro et al[68], 2022	I/II/III	IJS vs RBL	120	Reported	Reported	Not reported	Reported	Not reported	Not reported	Not reported	Reported	Not reported	Not reported	Not reported
Trenti et al[69], 2023	III/IV	HAL vs LigaH	75	Not reported	Not reported	Reported	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Reported	Not reported
Yang et al[70], 2022	II/III/IV	SH vs MLPPH	130	Not reported	Reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Not reported	Not reported	Not reported
Mert[71], 2023	III/IV	LASER vs FH	100	Not reported	Reported	Not reported	Reported	Not reported	Reported	Reported	Reported	Not reported	Reported	Not reported
Huang et al[72], 2023	III/IV	TST vs SH	306	Reported	Reported	Not reported	Not reported	Not reported	Reported	Reported	Not reported	Reported	Not reported	Not reported
Cemil et al[73], 2024	II/III	LASER vs MM	85	Not reported	Not reported	Not reported	Not reported	Not reported	Reported	Not reported	Not reported	Not reported	Reported	Not reported
Nada et al[74], 2024	III/IV	HarS vs SH	70	Reported	Not reported	Reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Reported	Not reported
Jin et al[75], 2024	II	LASER vs RBL	70	Reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Reported	Not reported	Reported	Not reported
Mustapha et al[76], 2025	II/III/IV	LigaH vs MM	52	Not reported	Reported	Reported	Reported	Not reported	Not reported	Reported	Not reported	Not reported	Reported	Not reported
Huang et al[77], 2025	III/IV	TST vs SH vs EPH	141	Not reported	Reported	Not reported	Not reported	Reported	Not reported	Reported	Not reported	Reported	Not reported	Not reported
Fernandez-Hurtado et al[78], 2025	III	HAL vs MM	50	Reported	Reported	Not reported	Reported	Not reported	Not reported	Reported	Not reported	Reported	Reported	Not reported

BPC: Bipolar coagulation; CHR: Combined hemorrhoidal radiocoagulation; DCV: Direct current electrotherapy; EPH: Eastern rubber band ligation and coincident of dislocation for prolapse and hemorrhoid; FH: Ferguson hemorrhoidectomy; HAL: Hemorrhoidal artery ligation; HarS: Harmonic scalpel hemorrhoidectomy; IJS: Injection sclerotherapy; IRC: Infrared coagulation; LASER: Laser hemorrhoidectomy; LigaH: LigaSure™ hemorrhoidectomy; MLPPH: Modified ligation procedure for prolapsed hemorrhoids; MM: Milligan–Morgan hemorrhoidectomy; MPSH: Modified Park’s submucosal hemorrhoidectomy; RBL: Rubber band ligation; RFC: Radiofrequency coagulation; SCH: Semi-closed hemorrhoidectomy; SH: Stapled hemorrhoidopexy; SLM: Suture ligation with mucopexy; TST: Tissue-selecting technique.

Table 2 Summary of surface under the cumulative ranking curve scores for all outcomes in the overall population

Treatment	Recurrence	Effectiveness	Satisfaction	Further treatment	Pain	Bleeding	Urinary retention	Septic complications	Anorectal stenosis	Incontinence	Constipation
MM	47.1	73.3	39.4	17.4	80.5	64.3	65.1	63.7	61.9	71.2	90.4
LigaH	19.3	98.2	39.1	4.3	82.5	60.5	75.4	62.7	48.2	70.4	64.6
FH	35.2	24.3	NA	71.8	54.2	54.7	61.6	84.9	98.6	94.6	NA
SH	63.9	60.6	66.5	39.6	59.9	60.9	56.3	71.2	52.9	68.8	47.2
MPSH	28.0	NA	NA	NA	NA	60.9	NA	NA	51.1	NA	NA
BPC	NA	NA	NA	NA	NA	95.1	79.8	27.4	NA	27.6	NA
MLPPH	NA	83.9	NA	NA	NA	NA	49.2	NA	NA	NA	NA
TST	20.9	69.7	61.9	24.6	29.8	54.2	40.6	NA	20.0	51.1	11.7
EPH	NA	61.9	NA	NA	63.4	NA	37.3	NA	64.9	NA	NA
HAL	80.4	36.2	46.8	58.8	59.6	37.4	57.6	76.5	27.1	48.9	21.1
RBL	90.5	16.3	29.9	73.3	36.9	41.5	49.6	23.6	NA	45.4	NA
IJS	76.4	22.6	30.2	69.5	13.5	58.4	NA	50.8	NA	NA	NA
SLM	72.4	42.0	57.7	54.8	55.5	45.2	40.6	29.1	41.3	8.3	64.9
IRC	69.0	9.4	NA	77.3	NA	18.3	NA	NA	NA	NA	NA
HarS	24.7	NA	78.5	28.7	75.9	26.6	35.6	26.8	86.6	24.9	NA
CHR	NA	30.2	NA	NA	NA	NA	NA	NA	NA	NA	NA
RFC	46.6	NA	NA	NA	NA	95.1	49.4	NA	59.8	88.4	NA
DCV	12.3	61.4	NA	99.0	0.4	17.1	68.5	44.8	NA	44.5	NA
SCH	49.8	NA	NA	NA	37.8	35.9	28.6	NA	4.7	15.3	NA
LASER	63.6	60.0	NA	30.8	NA	23.8	4.8	38.5	42.7	40.5	NA

NA indicates not available because of insufficient data. BPC: Bipolar coagulation; CHR: Combined hemorrhoidal radiocoagulation; DCV: Direct current electrotherapy; EPH: Eastern rubber band ligation and coincident of dislocation for prolapse and hemorrhoid; FH: Ferguson hemorrhoidectomy; HAL: Hemorrhoidal artery ligation; HarS: Harmonic scalpel hemorrhoidectomy; IJS: Injection sclerotherapy; IRC: Infrared coagulation; LASER: Laser hemorrhoidectomy; LigaH: LigaSure™ hemorrhoidectomy; MLPPH: Modified ligation procedure for prolapsed hemorrhoids; MM: Milligan–Morgan hemorrhoidectomy; MPSH: Modified Park’s submucosal hemorrhoidectomy; RBL: Rubber band ligation; RFC: Radiofrequency coagulation; SCH: Semi-closed hemorrhoidectomy; SH: Stapled hemorrhoidopexy; SLM: Suture ligation with mucopexy; TST: Tissue-selecting technique.