Intravenous sedation combined with local anesthesia versus spinal anesthesia for hemorrhoidectomy with rubber band ligation: A retrospective cohort study

BACKGROUND: Evidence comparing intravenous sedation combined with local anesthesia (IV + LA) versus spinal anesthesia (SA) for hemorrhoidectomy with concomitant rubber band ligation (RBL) is limited, particularly in the context of ambulatory-oriented pathways. METHODS: We conducted a single-center retrospective cohort study including consecutive adults undergoing hemorrhoidectomy with RBL between January 2024 and January 2026. Patients were grouped by anesthetic technique (IV + LA vs SA). The primary outcome was postoperative pain at 24 h measured by the numerical rating scale (NRS). Secondary outcomes included early pain at 6 h, rescue analgesia within 24 h, recovery metrics (time to meet discharge criteria), and anesthesia-related adverse events. Multivariable regression adjusted for prespecified confounders (age, sex, body mass index, American Society of Anesthesiologists class, operative time, extent of hemorrhoidectomy, number of bands, and year of surgery). Propensity-score inverse probability of treatment weighting (IPTW) and an additional sensitivity analysis stratified by calendar period were performed to assess the robustness of the findings. RESULTS: Among 220 screened patients, 146 were included (IV + LA, n = 72; SA, n = 74). NRS at 24 h was lower with IV + LA than with SA (1.2 ± 1.1 vs 2.1 ± 1.2; mean difference - 0.9, 95% CI - 1.27 to - 0.53; P < 0.001), although the magnitude of this difference was modest. Patients receiving SA required 5.5 ± 1.3 h to meet discharge criteria, compared with 2.8 ± 0.9 h in the IV + LA group (P < 0.001). Urinary retention requiring catheterization within 6 h occurred in 17 of 74 patients (23.0%) in the SA group and in none of the 72 patients in the IV + LA group (absolute risk difference, - 23.0 percentage points; P < 0.001). Because no urinary retention events occurred in the IV + LA group, the corresponding adjusted odds ratio should be interpreted cautiously owing to model instability from complete separation. In multivariable analysis, SA remained independently associated with higher NRS at 24 h (β = 0.92, 95% CI 0.56-1.26; P < 0.001), whereas higher odds of hypoxemia/oxygen supplementation were observed in the IV + LA group (adjusted OR 3.89, 95% CI 1.13-13.37; P = 0.014). IPTW diagnostics suggested improved covariate balance and adequate propensity-score overlap, and the direction of the association for the primary outcome was unchanged in sensitivity analyses stratified by calendar period. CONCLUSIONS: For hemorrhoidectomy with RBL, IV + LA and SA were associated with different perioperative trade-offs. Compared with SA, IV + LA was associated with modestly lower 24-h pain scores, faster discharge readiness, and fewer early urinary retention events requiring catheterization, but more frequent hypoxemia/oxygen supplementation. Given the retrospective design, temporal practice change, potential residual confounding, and non-standardized anesthetic protocols, these findings should not be interpreted as proof of superiority and should instead inform individualized anesthetic decision-making pending prospective confirmation.