Abstract
Purpose
The purpose of this study is to investigate the recurrence rates for the treatment of pilonidal sinus disease (PSD) in Turkey and the factors associated with recurrence of PSD after surgery on a nationwide scale.
Methods
This national, multicenter, database review was conducted in Turkey by the PISI TURKEY Research Group, and included recipients of PSD surgery in 41 select hospitals in Turkey, between January 2019 and January 2020. Data were collected by completion of standardized data forms. Sociodemographic and anthropometric data, comorbidities, PSD type, previous PSD interventions, index PSD intervention, recurrence, and complications were collected from baseline to postoperative 12 months.
Results
The data of 1662 patients from 41 centers were analyzed. The median age was 25 (21–32) years, and 80.26% of the cases were male. The recurrence rate following index operations was 6.26% in the 12-month period. Age (p = 0.594) and sex distribution (p = 0.441) were similar in patients with and without recurrence. The recurrent group had significantly higher frequencies of type V PSD (p < 0.001), wound site infection (p < 0.001), and wound separation (p < 0.001), whereas the non-recurrent group had a significantly higher frequency of type III PSD (p < 0.001). Multivariable logistic regression revealed that prior recurrence, postoperative wound site infection, and postoperative wound separation were independently associated with recurrence.
Conclusions
The recurrence rate after PSD surgery in Turkey was close to the lower ranges reported in prior literature. Turkish patients with a history of prior recurrence, postoperative wound site infection, or postoperative wound separation should be considered to have higher risks for recurrence.
Supplementary Information
The online version contains supplementary material available at 10.1007/s00384-025-04921-x.
Keywords: Pilonidal sinus, Survey, Recurrence, Wound site infection, Wound separation
Introduction
Pilonidal sinus disease (PSD), which exhibits a global prevalence of around 26 per 100,000 individuals, is a condition characterized by the infiltration of loose hair into hair follicles, typically situated within the natal cleft [1]. This phenomenon instigates an inflammatory cascade, resulting in the formation of midline pits, sinuses, or abscesses. Individuals afflicted with PSD commonly present with painful abscesses or a chronic cycle of recurrent pain and discharge from subcutaneous tracts. These symptoms impact physical and mental wellbeing and severely compromise quality of life [1, 2].
The management of PSD typically involves surgical interventions including excisional and non-excisional procedures [3]. The desired outcomes of such interventions include prompt resumption of normal activities, minimal complications, and avoidance of recurrence [1, 4, 5]. The frequency of recurrence after PSD surgery varies between 0 and 40% [6, 7]. Recurrence greatly affects long-term patient satisfaction following PSD surgery [8]. Some evidence suggests that recurrence is associated with the surgical procedure and is correlated with the length of follow-up [8–10]. However, the existing data are conflicting and the follow-up periods in different studies vary greatly, which raises questions about the validity of the reported recurrence rates associated with different surgical procedures or other risk factors. Moreover, there are very few studies of sufficient, scope, quality, and follow-up length that aim to identify factors associated with the risk of recurrence following PSD surgery. Therefore, the quest to determine the most effective management strategy which prevents adverse outcomes persists, necessitating further efforts to elucidate optimal interventions, outcomes, and factors that are uniquely associated with recurrence.
The heterogenous nature of PSD in terms of development, severity, and therapeutic approaches limits the accuracy of data drawn from smaller studies. As such, there is a need for comprehensive studies encompassing large populations to identify independent factors associated with treatment outcomes. Therefore, this nationwide study was conducted to investigate the characteristics of patients who underwent PSD, (i) to determine recurrence rates during a 12-month period and (ii) to identify factors associated with recurrence.
Material and methods
Ethical statement
All procedures performed were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Ethics Committee of Gazi University Faculty of Medicine (Decision date: February 22, 2021, decision no: #198). All data collected were pseudonymized to maintain the privacy of each subject.
Study design, setting, and population
This national, multicenter, database review, which was a part of the “Pilonidal sinus disease study: A national survey,” was conducted in Turkey by the PISI TURKEY Research Group. The study population consisted of patients who underwent PSD surgery in state or private university hospitals, training and research hospitals, city hospitals, public hospitals, or private hospitals in Turkey, between January 2019 and January 2020. Centers were selected on the basis of their capacity to deliver surgical interventions for PSD and their commitment to adhere to the standardized data collection protocol. The invitation to participate was extended to all public institutions, university-affiliated hospitals, and high-volume surgical centers throughout Turkey to ensure comprehensive national representation and institutional diversity.
Researchers
After obtaining ethical approval, researchers were invited to the study by e-mail. Each center was asked to form a team of maximum 6 investigators including 1 supervising faculty member/specialist physician, 4 physicians and/or research assistants, and 1 medical student. Team members from each center were responsible for identifying eligible patients, collecting baseline and follow-up data and transmitting the data. In each center, also 1 physician or medical student who had not participated in the data collection phase and whose role was to assess whether all patients who met the inclusion criteria of the study were included from the same center was recruited as an independent data validator. PISI TURKEY Research Group identified and approved potential investigators.
Inclusion and exclusion criteria
Patients eligible for the study were those who had undergone surgical intervention for PSD and were older than 18 years of age at the time of surgery. Patients younger than 18 years of age, those with Type 1 and Type 2 PSD, subjects with comorbidities that could significantly confound the relationships examined in this study (diabetes mellitus, hidradenitis suppurativa, irritable bowel disease, and connective tissue disorders), pregnant women, patients with sealant hypersensitivity, and those with missing data were excluded from the study.
Tools and definitions
After identifying the patients who were eligible for the study, the information included in the study was obtained from the hospitals’ computerized database records, patient charts, and by calling the patients by phone. The collected data detailed below were entered into the Research Electronic Data Capture (REDCap) system [11, 12], a remote web-based data collection system hosted by Gazi University, Ankara, Turkey. Only data sets that were ≥ 95% complete (for each center) were accepted for national analysis. The data from centers with > 5% missing data were not included in the analyses.
Data collection form
A case report form (patient data collection form) that was prepared specifically for the study was sent to each participating center to standardize data collection. Each research team who received the form filled it out with the details of eligible participants in their respective hospitals. This case report form included the following information about patients:
Sociodemographic data such as age, sex, and occupation
Preoperative height and weight information (using this information, body-mass index [BMI] was calculated as weight/height2 [kg/m2]).
Smoking and comorbidity status
PSD type during index operation
Type and duration of index operation
Postoperative antibiotic prophylaxis status at index operation
Drainage status after index operation
The duration of mobilization, hospital stay and return to normal activities after the index operation
Narcotic analgesic and non-steroidal anti-inflammatory drug (NSAID) use status after the index operation
Complications, wound healing, infection, and recurrence status after the index operation
Disease-related definitions
PSD severity was classified according to the Tezel classification [13]. This classification system categorizes sacrococcygeal PSD based on the anatomical location and clinical presentation. The classes are used in the guidance of treatment decisions:
Type I: Asymptomatic pits within the navicular area without a history of abscess or drainage.
Type II: Acute pilonidal abscess.
Type III: Pits within the navicular area with a history of abscess or previous drainage.
Type IV: Extensive disease with sinus opening(s) outside the navicular area, often associated with multiple abscess formations and drainages.
Type V: Recurrent pilonidal sinus following any surgical treatment.
Surgical intervention-related classifications
Surgical procedures performed for PSD were divided into two major groups: excisional procedures and non-excisional procedures. Primary closure, sinusectomy, secondary closure, and flap methods were considered excisional procedures, while crystallized phenol application, laser application and platelet‐rich plasma application were considered non-excisional procedures. Flap methods included the Bascom cleft lift, Karydakis, Limberg flap, and elliptical rotation flap procedures (Fig. 1). The excisional group was further stratified into the ‘Simple excision’ group (primary closure, sinusectomy, and secondary closure) and the “Excision + flap” group (all patients who received flap procedures).
Fig. 1.
Flow-chart of the study
Other variables and recurrence
Based on time to mobilization following the index intervention, patients were grouped as < 24 h and ≥ 24 h. Duration of hospitalization was categorized as follows: < 24 h, one day (< 48 h), two days (< 72 h), and three days or greater—according to length of stay in hospital after index operation. Wound site infection and recurrence status at 12 months after index surgery were recorded. The presence of discharge from the wound, abscess formation or a positive culture result from the site were defined as wound site infection. The definition of recurrence was the re-formation of pits and the presence of hair within the wound, given that the wound was completely healed after the intervention.
Statistical analysis
Statistical analyses were performed on SPSS for Windows, v25.0 (IBM Corp., Armonk, NY, USA), and significance was defined based on two-tailed p-values of less than 0.05. For the initial evaluation of continuous variables, normality of distribution was assessed via histograms and Q-Q plots. Variables meeting parametric assumptions were analyzed via parametric methods (Student’s t-test), while the remaining variables were tested non-parametrically (Mann–Whitney U). Descriptive statistics were presented with mean ± standard deviation for normally distributed continuous variables, while median (25 th percentile–75 th percentile) was used for non-normally distributed continuous variables. Categorical data were described with absolute frequency and relative frequency (groups). Between-groups comparisons of categorical variables were performed with appropriate chi-square tests or Fisher’s exact test. Multivariable logistic regression analysis (forward conditional selection method) was performed to determine significant factors independently associated with recurrence. The initial model entered into the forward conditional selection included all variables showing significant differences as a result of univariate analyses.
Results
Sixty-five centers accepted to participate in the study, but data from 24 centers that were not complete or did not meet validatory criteria were excluded. The data of 1865 patients from 41 centers were deemed eligible; however, 203 patients were excluded based on exclusion criteria. The final analyses comprised data from a total of 1662 patients from 41 centers (Fig. 1).
The median age of all participants was 25 (21–32) years and 80.26% (n = 1334) were males. The recurrence rate in the 12-month period after the index operation was 6.26% (n = 104). There was no significant difference between recurrent and non-recurrent groups in terms of age (p = 0.594), sex (p = 0.441), and BMI (p = 0.753). In the recurrent group, the frequencies of patients with type V PSD (p < 0.001), wound site infection (p < 0.001) and wound separation (p < 0.001) were significantly higher compared to the non-recurrent group, while the percentage of patients with type III PSD (p < 0.001) was significantly lower (Tables 1 and 2 and Fig. 2).
Table 1.
Summary of pre-operative variables with regard to PSD recurrence
| Recurrence | ||||
|---|---|---|---|---|
| Total (n = 1662) | No (n = 1558) | Yes (n = 104) | p | |
| Age | 25 (21–32) | 25 (21–32) | 25 (21–31.5) | 0.594 |
| Sex | ||||
| Male | 1334 (80.26%) | 1247 (80.04%) | 87 (83.65%) | 0.441 |
| Female | 328 (19.74%) | 311 (19.96%) | 17 (16.35%) | |
| Body mass index, kg/m2 | 25.94 ± 3.44 | 25.93 ± 3.44 | 26.04 ± 3.48 | 0.753 |
| Occupation | ||||
| Unemployed/Retired | 133 (8.77%) | 121 (8.53%) | 12 (12.24%) | 0.237 |
| Student | 532 (35.07%) | 506 (35.66%) | 26 (26.53%) | |
| Desk job | 239 (15.75%) | 221 (15.57%) | 18 (18.37%) | |
| Other jobs | 613 (40.41%) | 571 (40.24%) | 42 (42.86%) | |
| Smoking | 787 (47.35%) | 738 (47.37%) | 49 (47.12%) | 0.960 |
| Tezel classification (severity) | ||||
| Type III | 1007 (60.59%) | 975 (62.58%) | 32 (30.77%) | < 0.001 |
| Type IV | 461 (27.74%) | 438 (28.11%) | 23 (22.12%) | |
| Type V | 194 (11.67%) | 145 (9.31%) | 49 (47.12%) | |
Descriptive statistics were presented by using mean ± standard deviation for normally distributed continuous variables, median (25 th percentile–75 th percentile) for non-normally distributed continuous variables and frequency (percentage) for categorical variables.
PSD pilonidal sinus disease.
Table 2.
Summary of intra-operative and post-operative variables with regard to PSD recurrence
| Recurrence | ||||
|---|---|---|---|---|
| Total (n = 1662) | No (n = 1558) | Yes (n = 104) | p | |
| Surgery | ||||
| Simple excision | 247 (14.86%) | 232 (14.89%) | 15 (14.42%) | 0.819 |
| Excision + flap | 1148 (69.07%) | 1078 (69.19%) | 70 (67.31%) | |
| Non-excisional | 267 (16.06%) | 248 (15.92%) | 19 (18.27%) | |
| Antibiotic prophylaxis | 1062 (63.90%) | 995 (63.86%) | 67 (64.42%) | 0.908 |
| Duration of operation, min | 35 (20–50) | 35 (20–50) | 35 (25–60) | 0.789 |
| Drainage | 590 (35.50%) | 550 (35.30%) | 40 (38.46%) | 0.514 |
| Narcotic use for pain | 283 (17.03%) | 271 (17.39%) | 12 (11.54%) | 0.160 |
| NSAIDs use for pain | 1229 (73.95%) | 1150 (73.81%) | 79 (75.96%) | 0.629 |
| Mobilization | ||||
| < 24 h | 1618 (97.35%) | 1514 (97.18%) | 104 (100.00%) | 0.109 |
| ≥ 24 h | 44 (2.65%) | 44 (2.82%) | 0 (0.00%) | |
| Length of stay in hospital, days | ||||
| < 24 h | 120 (7.22%) | 115 (7.38%) | 5 (4.81%) | 0.734 |
| One day | 1408 (84.72%) | 1319 (84.66%) | 89 (85.58%) | |
| Two days | 104 (6.26%) | 96 (6.16%) | 8 (7.69%) | |
| Three days or above | 30 (1.81%) | 28 (1.80%) | 2 (1.92%) | |
| Postoperative complications | ||||
| Bleeding | 217 (13.06%) | 201 (12.90%) | 16 (15.38%) | 0.564 |
| Wound site infection | 164 (9.87%) | 133 (8.54%) | 31 (29.81%) | < 0.001 |
| Wound separation | 182 (10.95%) | 150 (9.63%) | 32 (30.77%) | < 0.001 |
| Systemic infection | 3 (0.18%) | 2 (0.13%) | 1 (0.96%) | 0.176 |
| Return to normal activities, days | 7 (3–19) | 7 (3–19) | 10 (4–20) | 0.239 |
Descriptive statistics were presented by using median (25 th percentile–75 th percentile) for non-normally distributed continuous variables and frequency (percentage) for categorical variables.
NSAID nonsteroidal anti-inflammatory drugs, PSD pilonidal sinus disease.
Fig. 2.
Postoperative wound site infection and wound separation frequencies with regard to recurrence
Multivariable analysis revealed that Type V PSD (OR: 8.108, 95% CI: 5.243–12.540, p < 0.001), postoperative wound site infection (OR: 2.754, 95% CI: 1.570–4.832, p < 0.001), and postoperative wound separation (OR: 2.491, 95% CI: 1.432–4.332, p = 0.001) were the factors that were independently associated with recurrence (Table 3).
Table 3.
Significant factors independently associated with the PSD recurrence, multivariable logistic regression analysis
| β coefficient | Standard error | p | Exp(β) | 95.0% CI for Exp(β) | ||
|---|---|---|---|---|---|---|
| Tezel classification (type V) | 2.093 | 0.222 | < 0.001 | 8.108 | 5.243 | 12.540 |
| Postoperative wound site infection | 1.013 | 0.287 | < 0.001 | 2.754 | 1.570 | 4.832 |
| Postoperative wound separation | 0.913 | 0.282 | 0.001 | 2.491 | 1.432 | 4.332 |
| Constant | − 3.568 | 0.158 | < 0.001 | 0.028 | ||
Nagelkerke R2 = 0.197.
CI confidence interval, PSD pilonidal sinus disease.
Post hoc analysis was performed to assess the clinical significance of postoperative complications independently associated with recurrence. Among patients who experienced postoperative wound site infection, the recurrence rate was substantially higher (18.9%) compared to those without infection (4.9%), corresponding to an absolute risk increase of 14.0% and a number needed to treat of 7. Similarly, patients with wound separation demonstrated a recurrence rate of 17.6%, in contrast to 4.9% in those without separation, translating to an absolute risk increase of 12.7% and a number needed to treat of 8.
Discussion
This national survey study revealed a recurrence rate of 6.3% (at 12-month follow-up) after PSD interventions in Turkey. Independent risk factors associated with recurrence were identified as prior recurrence, postoperative wound site infection, and postoperative wound separation. Notably, while the type of intervention was not associated with recurrence, specific postoperative complications such as wound infection and wound separation significantly increased recurrence risk. Our post hoc analysis regarding the number needed to treat for modifiable postoperative complications revealed that prevention of wound site infection and wound separation could potentially prevent one recurrence for every 7 and 8 patients treated, respectively. These data emphasize the substantial clinical relevance of rigorous postoperative wound management and implementation of targeted preventive measures to mitigate the risk of recurrence in patients with pilonidal sinus disease.
The primary challenge in the treatment of PSD is recurrence, which has been reported to range from 0 to 40% depending on patient characteristics, intervention, and the specific type of surgery utilized in treatment [6, 7]. In our study, the recurrence rate at 12-month follow-up after PSD surgery was 6.3%, which appears to be directly associated with type V PSD and adverse outcomes concerning the wound site. The success or failure of PSD therapy hinges on the extent of inflammation and wound site characteristics, which have been previously identified as impacting treatment outcomes, wound healing, and the likelihood of disease recurrence [14, 15]. Although the association between wound complications and recurrence may appear intuitive, our investigation represents one of the first to establish this relationship through robust multivariable analysis in a large-scale, real-world patient cohort. Although it is evident that recurrent disease reduces the long-term satisfaction of patients undergoing PSD surgery [16], data on this topic remain inconclusive due to small studies and unclear characterization of patients and management strategies. While the relationship between prior recurrence and increased risk of subsequent recurrence is well-documented, our study confirms this association in a large, nationwide population. This validation in a real-world clinical setting enhances the external validity and clinical applicability of this finding. Identifying independent risk factors that increase the risk of recurrence can greatly contribute to minimizing poor outcomes and improving quality of life and satisfaction among patients. Interestingly, our national multicenter analysis revealed no significant association between the surgical approach and the likelihood of recurrence, a finding that may appear to contradict previous literature. This observation, however, warrants interpretation within the context of real-world clinical practice, where surgeons frequently select surgical techniques based on disease severity, reserving more complex procedures for more advanced cases, potentially balancing recurrence risk across groups. Additionally, since pilonidal disease primarily affects working-age individuals, patient preferences often prioritize quicker recovery over lower recurrence risk. These factors may explain the lack of significant differences between techniques in our nationwide cohort.
In the multicenter “Pilonidal Sinus Treatment Studying the Options” (PITSTOP) study carried out in the UK, recurrence rate at 6 months of intervention was reported as 16.8% among 667 participants [1]. In a systematic review and meta-analysis, the overall incidence of recurrent disease after PSD surgery was reported to be 8% [17]. For a longer time-frame after surgery (5-year follow-up) a meta-analysis of relevant studies showed an overall recurrence rate of 13.8% [14]. Notably, the authors found a higher incidence of recurrence within 5 years among those undergoing the open healing approach compared to primary closure. Furthermore, the analyses showed an unprecedented 10% recurrence frequency with the out-midline approach, which was previously thought to be an excellent intervention based on the exceedingly low recurrence frequency at 1 year of follow-up (0.79%) [14], which fuels the notion that data from smaller studies tend to be impacted by various biases. A mini-review investigating the recurrence rates of some minimally-invasive treatment procedures (including conservative treatments, endoscopic procedures and the Seton technique) found that recurrence rates ranged from 1% (at 18 months with conservative treatment) to 15.3% (at 112 months) [18]. The findings with Seton and endoscopic methods were in close agreement with previously published data [18]. A holistic review of the most convincing literature on this topic indicates that the incidence of recurrence for primary midline closure ranges between 8.4% and 11.7% within the first postoperative year, while corresponding data for the open healing strategy puts recurrence frequency between 2.1% and 4.5% [17, 19, 20]. The recurrence rate in our study was close to the lower intervals reported for overall analyses in the literature. When examined separately, recurrence rates were 6.1–7.1% across the different treatment groups included in the study, without any significant differences.
In the studies by Mutus et al. and Almajid et al., the recurrence rate after PSD surgery was found to be 7.8% and 7.2%, respectively [3, 21]. Which are also congruent with the recurrence rates in our study. Most importantly, the authors of these studies reported that all patients who experienced recurrence had abundant hair in the intergluteal area and poor local hygiene, and furthermore, Mutus et al. found that none of the patients who had undergone laser hair removal had experienced recurrence [3], which is supported by other research [22, 23]. Almajid et al. described that younger age, prolonged sitting, and higher BMI were associated with an increased likelihood of disease recurrence [21]. In a retrospective study from Turkey, a substantial number of recurrences, comprising 27%, 58%, and 79%, were observed within the first 6 months, first year, and first 2 years, respectively [24]. Recurrence was associated with a multitude of parameters, including BMI, family history, bathing habits, hair overgrowth, skin characteristics, smoking, presence of abscess(es), and duration of symptoms. Among the treatment methods, Limberg flap repair demonstrated the highest success rate [24]. It is also crucial to consider that studies reporting higher recurrence rates, due to the sheer size of their recurrent population, may be able to identify rarer factors associated with recurrence. For instance, in a retrospective study reporting a 22.8% recurrence rate, the authors found that advanced age and post-operative seroma fluid discharge were independent risk factors for recurrence, while preoperative antibiotic prophylaxis and hair removal were effective in reducing recurrence likelihood [25]. Similar to our study, the type of surgical closure showed no significant impact on recurrence; however, primary closure was associated with earlier recurrence compared to secondary closure [25]. A retrospective review focusing on pediatric patients with PSD revealed an overall recurrence rate of 33%. It was determined that individuals with obesity were the sole group exhibiting an independent association with the timing of disease recurrence [26]. Nonetheless, there are a number of studies that have shown no association between high BMI and recurrence [10, 27]. Other rare associations with recurrence after PSD surgery include factors such as ethnicity, young age at presentation, familial predisposition, sinus discharge upon physical examination, size of excision, and sex [10, 27–32]. Given the various factors found to influence recurrence rates in patients with PSD, different populations may have different factors that increase susceptibility to recurrence. This supports the idea of studying each population comprehensively to understand its own characteristics. Our comprehensive, multicenter study was carried out for this purpose.
Patients suffering from PSD are typically working-age and greatly contribute to society. Delays in healing or return to normal activities not only affects individuals but also carries broader repercussions. Moreover, ongoing costs associated with chronic treatment and healthcare resource use further compound the economic impact [1]. The most important finding of our study was that prior recurrence (type V PSD), wound site infection, and wound separation were associated with increased risk of recurrence in our population. Surgeons should consider higher risks for recurrence in these patients, thereby facilitating necessary measures. However, when interpreting the results regarding recurrence, it is important to consider the ambiguity surrounding the definition of recurrence. True recurrence, which is the reappearance of the disease, is likely rarer than reported in many studies and requires a prolonged follow-up period for precise detection [1, 14]. In our study, a 12-month period was utilized to investigate post-surgical recurrence of the disease, which is longer than many previous studies of the same scale and comprehensiveness. However, longer follow-up might be needed to determine long-term recurrence and its frequency. Additional research, comprising randomized controlled trials and extended follow-up, is necessary to improve existing evidence and provide guidance for clinical decision-making.
Limitations
Some limitations should be considered when interpreting our results. The most important limitation is that the data were obtained from prospectively collected databases. The inevitable differences in the number of patients with recurrence based on intervention groups may have negatively affected statistical analyses. Finally, due to the large number of variables included in the study, the effect of cases with multiple recurrences was ignored and detailed analyses for these marginal cases were not performed.
Conclusion
At 12-month follow-up, the recurrence rate was 6.3% in our nationwide cohort of patients who underwent treatment for PSD—a lower value relative to many previous studies. The factors demonstrating the strongest independent association with recurrence were prior history of recurrence, postoperative wound site infection, and wound separation—underscoring that successful outcomes in PSD surgery depend not solely on the selected surgical approach, but critically on the quality of postoperative wound healing. Surgeons'consideration of these factors will contribute to reducing recurrence rates and improving quality of life after PSD treatment. Future studies with longer follow-up are needed to assess factors associated with delayed recurrence.
Supplementary Information
Below is the link to the electronic supplementary material.
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Author contributions
Ali Yalcinkaya: Conceptualization; data curation; formal analysis; writing – original draft; methodology; investigation; writing – review and editing; software; visualization; project administration. Ahmet Yalcinkaya: Conceptualization; data curation; formal analysis; writing – original draft; methodology; investigation; writing – review and editing; software; visualization; project administration. Can Sahin: Conceptualization; data curation; formal analysis; methodology; investigation; software; visualization; project administration. Bengi Balci: Conceptualization; data curation; formal analysis; methodology; investigation; software; visualization; project administration. Elif Ozeller: Conceptualization; data curation; formal analysis; methodology; investigation; software; visualization; project administration. Ece Ozturk: Conceptualization; data curation; formal analysis; methodology; investigation; software; visualization; project administration. Gulsum Sueda Kayacan: Conceptualization; data curation; formal analysis; methodology; investigation; software; visualization; project administration. Berkay Enes Karaca: Conceptualization; data curation; formal analysis; methodology; investigation; visualization; project administration. Ahmet Faruk Oyanik: Conceptualization; data curation; formal analysis; methodology; investigation; visualization; project administration. Aydin Yavuz: Writing – original draft; methodology; investigation; supervision; writing – review and editing; validation; resources; software. Erdinc Kamer: Writing – original draft; methodology; investigation; supervision; writing – review and editing; validation; resources; software. Sezai Leventoglu: Writing – original draft; conceptualization; methodology; investigation; supervision; writing – review and editing; validation; resources; software, supervision.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
The datasets in this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval
All procedures performed were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Ethics Committee of Gazi University Faculty of Medicine (Decision date: February 22, 2021, decision no: #198).
Competing interests
The authors declare no competing interests.
Footnotes
Ali Yalcinkaya and Ahmet Yalcinkaya contributed equally to this work and share joint first authorship.
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Change history
11/11/2025
A Correction to this paper has been published: 10.1007/s00384-025-05024-3
Contributor Information
Sezai Leventoglu, Email: sezaileventoglu@hotmail.com.
PISI TURKEY Study Collaboration:
Sezai Leventoglu, Bengi Balci, Ali Yalcinkaya, Alp Ozgun Borcek, Elif Ozeller, Ece Ozturk, Gulsum Sueda Kayacan, Berkay Enes Karaca, Ahmet Faruk Oyanik, Omer Faruk Gul, Basak Bolukbasi, Huseyin Gobut, Cagri Buyukkasap, Aydin Yavuz, Dara Aydin, Zeynep Akdagcik, Alina Pataeva, Douigou Hasan, Omar Hussein, Arda Ozgur Ozturk, Cem Arda Elumar, Ali Derman Dere, Asra Zeynep Balci, Rasim Ozturk, Ali Derman Dere, Asra Zeynep Balci, Rasim Ozturk, Yasar Copelci, Murat Kartal, Serkan Tayar, Mustafa Yeni, Tolga Kalayci, Ramazan Yavuz, Bulent Calik, Semra Demirli Atici, Selen Ozturk, Gizem Kilinc, Korhan Tuncer, Cengiz Aydin, Mustafa Yener Uzunoglu, Yildiz, Aybala Yildiz, Can Sahin, Mehmet Caglikulekci, Elbrus Zarbaliyev, Murat Sevmis, Baris Sevinc, Nurullah Damburaci, Omer Karahan, Ozgen Isik, Said Kural, Xhenet Hysejni, Ahmet Aktas, Baris Yildiz, Gultekin Ozan Kucuk, Ahmet Can Sari, Mert Candan, Mehmet Mahir Ozmen, Cem Emir Guldogan, Emre Gundogdu, Munevver Moran, Mevlut Recep Pekcici, Saygin Altiner, Enes Cebeci, Tugba Yigit, Bedri Burak Sucu, Mert Col, Omer Faruk, Ozkan Hanife, Seyda Ulgur, Murat Kalin, Emre Furkan Kirkan, Abdullah Yildiz, Sema Yukseksag, Cagri Buyukkasap, Erdinc Kamer, Mesut Ozogul, Nihan Acar, Melek Gokova Bekler, Arif Atay, Halis Bag, Server Sezgin Uludag, Ahmet Necati Sanli, Sefa Ergun, Ergin Erginoz, Veysi Basbayandur, Mehmet Faik Ozcelik, Ahmet Askar, Yuksel Altinel, Adnan Hacim, Serhat Meric, Merve Tokocin, Talar Aktokmakyan, Yunus Aktimur, Kamil Ozdogan, Fikret Calikoglu, Tugba Koc Calikoglu, Ahmet Barcin, Ahmed Salhat, Guray Durmaz, Volkan Ozben, Erman Aytac, Zumrud Aliyeva, Arda Ulas Mutlu, Mert Tanal, Mustafa Fevzi Celayir, Aydin Eray, Tufan Ali Yuksel, Elif Baran, Banu Yigit, Erhan Eroz, Aykhan Abbasov, Hakan Yanar, Huseyin Onur Aydin, Murathan Erkent, Tugan Tezcaner, Tevfik Avci, Murat Kus, Mehmet Abdussamet Bozkurt, Adem Ozcan, Nezihe Berrin Dodur Onalan, Serhan Yilmaz, Yasin Kara, Ali Kocatas, Fatih Yanar, Ali Fuat Kaan Gok, Irem Karatas, Berke Sengun, Ilknur Erenler Bayraktar, Onur Bayraktarn, Zulal Emsal, Irem Dalkilic, Cengiz Dibekoglu, Sami Acar, Erman Ciftci, Yunus Yapalak, Cihad Tatar, Mert Mahsuni Sevinc, Ali Emre Nayci, Egemen Saygili, Yavuz Selim Komek, Bayram Kaymak, Fatih Altintoprak, Emrah Akin, Necattin Firat, Emre Gonullu, Ugur Can Dulger, Atilla Kurt, Sinan Soylu, Musa Serin, Omer Topcu, Ali Cihat Yildirim, Mehmet Fatih Ekici, Sezgin Zeren, Ismail Ahmet Bilgin, Tayfun Karahasanoglu, Ismail Hamzaoglu, Afag Aghayeva, Bilgi Baca, Inci Sahin, Osman Bozbiyik, Mustafa Ozgur Kilincarslan, Mustafa Ali Korkut, Erhan Akgun, Cemil Caliskan, Tayfun Yoldas, Timucin Erol, Hilmi Anil Dincer, Omer Cennet, Muhammed Salih Suer, Muhammet Bunyamin Dalkilic, Ibrahim Alkan, Busenur Kirimtay, Emre Balik, Emre Ozoran, Ibrahim Halil Ozata, Derya Salim Uymaz, Tutku Tufekci, Salih Nafiz Karahan, Orhan Agcaoglu, Naciye Cigdem Arslan, Mehmet Yilmaz, Orhan Ureyen, Can Murat Kale, Enver Ilhan, Eray Kara, Semra Tutcu Sahin, Onur Haspolat, Alperen Dalkiran, Ergun Yuksel, Mehmet Kocaoglu, Omer Tasan, Cevdet Tokat, Cihan Ozen, and Alptug Mertcan Koc
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
The datasets in this study are available from the corresponding author upon reasonable request.