Routine Histology After Hemorrhoidectomy: Uncovering the Hidden Risk of Malignancy?

Histological examination of hemorrhoidectomy specimens is often omitted in clinical practice on the assumption that macroscopic assessment reliably excludes malignancy. However, omission of histological examination may be associated with missed incidental pathology. This study evaluated local rates of histology submission following hemorrhoidectomy and the incidence and nature of unexpected findings, including malignancy.

A retrospective observational analysis was conducted of all adult patients undergoing hemorrhoidectomy at a large United Kingdom National Health Service (NHS) teaching hospital from January 2017 to April 2025. Electronic operative and pathology records were reviewed to determine demographics, histology submission, and final diagnoses. Statistical analyses were performed using IBM SPSS version 29. Associations between categorical variables were assessed using the chi-square test, and median ages were compared using the Mann-Whitney U test, with statistical significance defined as P < 0.05.

A total of 548 patients underwent hemorrhoidectomy, of whom 190 specimens (34.67%) were submitted for histopathological examination and 358 (65.33%) were discarded. There were no significant differences in median age (49 versus 51 y, P = 0.166) or sex distribution (36.0% versus 33.5% male, P = 0.526) between cases with and without histology submission. Among the 190 examined specimens, 175 (92.10%) demonstrated hemorrhoidal tissue alone, while 13 (6.84%) revealed unexpected benign pathology. Two specimens (1.05%) demonstrated clinically significant neoplastic pathology: one invasive squamous cell carcinoma and one high-grade anal intraepithelial neoplasia.

Only one-third of hemorrhoidectomy specimens were submitted for histological examination, yet a small but clinically important proportion of submitted specimens revealed unexpected neoplastic pathology. Reliance on macroscopic assessment alone may be associated with missed disease. Routine or selective histological submission based on standardized criteria may be associated with improved diagnostic safety and quality assurance in colorectal surgery.