What are the Latest Minimally Invasive Treatments for Hemorrhoids?
Introduction
Hemorrhoids, a common anorectal condition, significantly impact the quality of life for a substantial portion of the global population. Characterized by the swelling and inflammation of veins in the rectum and anus, hemorrhoids can manifest with symptoms ranging from discomfort and itching to bleeding and prolapse [1]. Historically, surgical interventions were the primary recourse for symptomatic hemorrhoids, particularly for advanced stages. However, these procedures often entail considerable postoperative pain, prolonged recovery periods, and potential complications such as anal stenosis or fecal incontinence [1]. Consequently, there has been a notable shift in clinical practice towards the development and adoption of **minimally invasive treatments (MITs)**. These approaches aim to alleviate symptoms effectively while minimizing patient discomfort, reducing recovery times, and lowering the incidence of adverse events. This article provides an academic overview of the latest advancements in minimally invasive treatments for hemorrhoids, drawing upon recent research and clinical findings to highlight their mechanisms, efficacy, and safety profiles.
Hemorrhoidal Artery Embolization (HAE)
Hemorrhoidal Artery Embolization (HAE) represents a significant innovation in the management of internal hemorrhoids, particularly for those presenting with bleeding symptoms. This interventional radiological procedure operates on the principle of reducing blood flow to the hemorrhoidal cushions, thereby promoting their shrinkage and alleviating symptoms. The procedure typically involves the insertion of a small catheter, often through an artery in the wrist or upper thigh, guided by advanced imaging techniques [2]. An angiogram is then performed using contrast dye to precisely identify the superior rectal arteries supplying the hemorrhoidal tissue. Once these target vessels are located, a microcatheter is advanced to deliver tiny embolic particles or coils, effectively blocking the abnormal blood flow [2].
One of the primary advantages of HAE is its minimally invasive nature, often performed as an outpatient procedure with minimal recovery time. Patients typically experience less pain compared to traditional surgical methods, making it an attractive option for individuals seeking to avoid the discomfort and downtime associated with surgery [2]. Clinical studies have demonstrated the efficacy and safety of HAE. A randomized clinical trial involving 33 patients, for instance, found that HAE resulted in similar resolution of bleeding-related symptoms as hemorrhoidectomy, but with significantly fewer adverse events such as swelling, wound openings, and anal fissures in the HAE group [2]. While HAE is particularly effective for bleeding hemorrhoids, its role in managing prolapse or other symptoms may vary, and patient selection remains crucial for optimal outcomes.
Office-Based Treatments: Advancements and Combinations
Office-based treatments continue to evolve, offering effective solutions for early to moderate-stage hemorrhoids. These procedures are typically performed in an outpatient setting, requiring minimal anesthesia and recovery.
Rubber Band Ligation (RBL) and Modified Approaches
**Rubber Band Ligation (RBL)** has long been a cornerstone of office-based hemorrhoid treatment, known for its effectiveness in treating grade I-III internal hemorrhoids. The procedure involves placing a small rubber band around the base of the hemorrhoid, cutting off its blood supply, leading to necrosis and eventual sloughing [1]. Recent advancements have focused on modifying RBL techniques to enhance efficacy and reduce complications. For example, modified RBL methods, which may involve suctioning the mucosa and submucosa or using polymer clips with stronger binding forces, have shown improved outcomes, including reduced postoperative pain and lower recurrence rates compared to traditional RBL or even excisional hemorrhoidectomy in some studies [1]. The use of polymer clips, for instance, has demonstrated significant advantages in terms of delayed bleeding rates and higher one-year success rates, suggesting a potential for reduced anal stenosis and improved tissue lifting effects [1].
Sclerotherapy
**Sclerotherapy** involves the injection of a chemical solution (sclerosant) into the hemorrhoidal tissue, causing inflammation, fibrosis, and shrinkage. While effective, its comparative efficacy against RBL has been debated, with some meta-analyses suggesting similar recurrence rates but potentially lower post-procedure pain for sclerotherapy [1]. A notable advancement in sclerotherapy is the use of **polidocanol in foam form**. Polidocanol, originally used for saphenous incompetence, has shown promising results in treating grade II-IV hemorrhoids, with high patient satisfaction and minimal pain reported in large patient cohorts [1]. However, safety considerations, such as the potential for anaphylactic shock, necessitate careful patient selection and further validation [1].
An innovative combined approach, **sclerobanding**, integrates RBL with sclerotherapy. This technique involves applying a rubber band followed by the injection of a sclerosant. Studies on sclerobanding, particularly in patients on anticoagulant therapy, have indicated its safety and efficacy, with a low complication rate and reduced risk of bleeding. The combination is thought to leverage the benefits of both treatments, with banding limiting the excessive submucosal spreading of the sclerosant, thereby maximizing therapeutic effects while minimizing drawbacks [1].
Energy Therapies
Energy-based therapies represent another evolving frontier in minimally invasive hemorrhoid treatment, aiming to induce necrosis and fibrosis of hemorrhoidal tissue through controlled energy delivery. **Infrared Coagulation (IRC)**, which uses infrared light to coagulate the tissue, has been a traditional method, but newer modalities are emerging. **Hemorrhoid Energy Therapy (HET)**, for instance, utilizes a bipolar device that generates less heat compared to IRC, potentially reducing the risk of collateral tissue damage [1]. Clinical results for HET have indicated reduced pain and hemorrhoid symptoms in patients with grade I-II hemorrhoids [1].
**Radiofrequency Ablation (RFA)**, particularly techniques like the Rafaelo procedure, employs radiofrequency waves to induce tissue plication and improve symptoms. While systematic reviews have reported high patient satisfaction and low recurrence rates, the level of evidence is often considered low due to the lack of randomized controlled trials and small information size [1].
**Laser Hemorrhoidoplasty (LH)** is currently one of the most actively researched energy therapies. This technique involves inserting a laser probe into the hemorrhoidal tissue to coagulate it. Meta-analyses comparing LH with conventional hemorrhoidectomy have demonstrated significant advantages for LH, including shorter surgery times, less intraoperative bleeding, lower postoperative pain, reduced analgesic use, and faster return to daily activities [1]. However, most studies report follow-up results only up to one year, and the debate continues regarding its clear advantage over conventional hemorrhoidectomy, especially considering similar costs to RFA and the need for more extensive anesthesia compared to some office-based procedures [1].
Surgical Innovations: Modified Stapled Hemorrhoidopexy (SH) and Mixed Techniques
For more advanced hemorrhoidal disease, surgical innovations have focused on refining existing techniques to reduce complications and improve long-term outcomes.
Modified Stapled Hemorrhoidopexy (SH)
**Stapled Hemorrhoidopexy (SH)**, while offering less pain than traditional excisional hemorrhoidectomy, has been associated with unique complications such as anastomosis stenosis, rectovaginal fistula, and rectal perforation [1]. To address these concerns, modified SH techniques have been developed. The **Tissue Selecting Technique (TST)**, for example, avoids circular stapling by using an anoscope with bi- or tri-windows to staple specific areas of mucosa and submucosa, thereby reducing the risk of complications associated with circular resection [1]. Another modification, SH using a “large C suture,” aims to preserve certain areas of mucosa and submucosa, further mitigating the risk of anal stenosis and rectovaginal fistula [1]. Research continues to explore optimal stapling height and compression times to minimize postoperative bleeding and other adverse events [1].
Mixed Operative Treatments
For patients presenting with both significant internal and external hemorrhoids, a single surgical approach may be insufficient or carry a high risk of complications. In such cases, **mixed operative treatments**, combining two or more surgical techniques, have shown promise. For instance, combining excisional hemorrhoidectomy (EH) with SH has been found to not increase complications or recurrence rates while significantly improving the quality of life for patients with significant external hemorrhoids [1]. Similarly, adding Hemorrhoidal Artery Ligation (HAL) to excisional procedures like Milligan-Morgan hemorrhoidectomy (MMH) or SH for grade III-IV hemorrhoids has demonstrated improved outcomes, including faster wound healing, shorter hospital stays, lower pain scores, and reduced complication rates [1]. Notably, studies suggest that HAL can be effective even without Doppler guidance, further simplifying the procedure and improving patient satisfaction [1].
Conclusion
The landscape of hemorrhoid treatment is continuously evolving, with a clear trend towards less invasive and more patient-friendly approaches. Minimally invasive treatments such as Hemorrhoidal Artery Embolization, advanced office-based procedures like modified RBL and foam sclerotherapy, and energy-based therapies including Laser Hemorrhoidoplasty, offer effective alternatives to traditional surgery. Furthermore, surgical innovations, such as modified stapled hemorrhoidopexy and mixed operative techniques, aim to enhance efficacy while minimizing complications for more complex cases. The selection of the most appropriate treatment modality depends on various factors, including the grade and type of hemorrhoids, patient symptoms, comorbidities, and individual preferences. As research progresses, a deeper understanding of these treatments will facilitate the development of standardized protocols and personalized treatment plans, ultimately improving patient outcomes and quality of life. It is crucial for healthcare professionals to stay abreast of these advancements to offer well-informed options to their patients.
References
1. Kang, S. I. (2025). Latest Research Trends on the Management of Hemorrhoids. *J Anus Rectum Colon*, *9*(2), 179–191. [https://pmc.ncbi.nlm.nih.gov/articles/PMC12035339/](https://pmc.ncbi.nlm.nih.gov/articles/PMC12035339/) 2. Kademani, M. (2025, July 15). *Hemorrhoidal artery embolization: A novel approach to internal hemorrhoids treatment*. UCLA Health. [https://www.uclahealth.org/news/article/hemorrhoidal-artery-embolization-novel-approach-internal](https://www.uclahealth.org/news/article/hemorrhoidal-artery-embolization-novel-approach-internal)