Abstract
Background
Various surgical modalities exist for the management of pilonidal sinus disease (PSD), with an increasing trend toward minimally invasive techniques. Sinus Laser associated Closure (SiLaC) and endoscopic pilonidal sinus treatment (EPSiT) are two minimally invasive techniques widely used in clinical practice. However, a systematic comparison of both techniques is lacking. This study conducted separate single-arm analyses of both techniques to compare their efficacy and safety.
Objective
A systematic literature search was performed across electronic databases including Web of Science, Embase, the Cochrane Library, Google Scholar and PubMed to identify relevant studies investigating SiLaC versus EPSiT for PSD. The primary outcome measures included operative time, cure rate, recurrence rate, postoperative complication rate, and total wound healing time.
Results
A total of 29 studies were included. The mean operative time was 18.02 min (95% CI:13.42–22.62; I2 = 99.4%; P < 0.001) for SiLaC and 30.11 min (95% CI: 21.33–38.88; I² = 98.5%; P < 0.001) for EPSiT. The cure rate was 86% (95% CI: 80–91%; I2 =92%; P < 0.001) in the SiLaC and 88% (95% CI: 83–94%; I² = 87.1%; P < 0.001) in the EPSiT group. The pooled recurrence rate was 11% (95% CI: 6–15%; I2 = 90.4%; < 0.001) for SiLaC and 9% (95% CI: 5–12%; I² = 82.9%; P < 0.001) for EPSiT. The complication rate was 10% (95% CI: 7–14%; I2 = 79.6%; P < 0.001) for SiLaC and 7% (95% CI: 1–15%; I² = 74.7%; P < 0.05) for EPSiT. The mean total healing time was 30.08 days (95% CI: 22.73–37.43%; I2 = 99.2%; P < 0.001) for SiLaC and 26.55 days (95% CI: 24.40–28.70; I² = 90.9%; P < 0.001) for EPSiT.
Conclusion
This indirect comparative analysis suggests comparable efficacy between SiLaC and EPSiT for PSD based on currently available, predominantly single-arm studies. These findings, limited by the lack of direct comparative trials, highlight the urgent need for prospective investigations to establish robust comparative effectiveness.
Keywords: Pilonidal sinus disease, Laser treatment, SiLaC, Endoscopic pilonidal sinus treatment, EPSiT
Introduction
PSD is a chronic disorder predominantly affecting the sacrococcygeal region, with a higher incidence among young males (approximately 26 per 100,000) [1, 2]. Current evidence identifies obesity, prolonged sedentary behavior, hirsutism, and local perianal irritation as risk factors for PSD. The acute phase is characterized by swelling and pain in the sacrococcygeal area, while the chronic phase often presents with persistent discharge [3].
Although numerous surgical approaches have been described for PSD, ranging from wide excision with midline closure to various flap techniques, yet a standardized surgical protocol remains elusive [4]. An ideal surgical technique should feature minimal tissue less pain, low recurrence rates, short hospitalization, early return to daily activities, minimal scarring, and technical feasibility [5, 6]. Consequently, novel minimally invasive techniques have gained considerable traction in clinical practice [4].
Among minimally invasive interventions, laser therapy and endoscopic treatment are currently widely used. Endoscopic treatment for PSD was first described by Meinero in 2013, and its core principle involves the visual debridement of sinus tract contents and hair debris using a fistuloscope system [5]. In contrast, laser ablation (or laser-assisted closure) for PSD employs a laser fiber to thermally ablate and obliterate the sinus tract [7]. Existing literature has validated high clinical success rates with acceptable recurrence rates for both techniques [8, 9]. Recently, an international consortium of experts from the International Society of Laser Proctology, ISoLP published a position paper specifically addressing the standardization of SiLaC and its combined application with EPSiT (E-SiLaC) [10]. This position paper outlines indications, procedural details, and attempts to homogenize practice for both stand-alone laser and combined laser-endoscopic approaches. Importantly, the authors of this position paper explicitly acknowledge the foundational limitation of the current evidence base, stating that it is “limited to small retrospective series“ [10]. Therefore, the present study aimed to synthesize available evidence via a systematic review and meta-analysis to evaluate and compare the efficacy and safety of laser therapy versus endoscopic treatment in the management of PSD.
Methods
This study was conducted in accordance with the Cochrane Handbook Systematic Reviews of Interventions and reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic literature search was performed using the Web of Science, Embase, Cochrane Library, PubMed and ClinicalTrials.gov. Search terms included: “PSD,” “pilonidal sinus,” “pilonidal sinus disease,” “pilonidal disease,” “SiLaC,” “SILAT,” “Laser,” “Laser Ablation,” “EPSiT,” “ClinicalTrials.gov,”and “endoscopic pilonidal sinus treatment.” The systematic review protocol was registered on PROSPERO(CRD420251274562).
Inclusion and exclusion criteria (PICOS)
Given the scarcity of direct comparative studies between SiLaC and EPSiT, separate single-arm analyses were performed. For the sake of uniformity, SiLaC was used as an umbrella term for all laser – assisted procedures for PSD (SiLaC, SiLaT, PiLaT, etc.).
P (Population): Patients diagnosed with pilonidal sinus disease.
I (Intervention/Comparator): Patients undergoing laser ablation or endoscopic treatment.
(Outcomes): Studies reporting any of the following outcomes: operative time, cure rate, recurrence rate, postoperative complications, and total healing time.
S (Study Design): Randomized or non-randomized clinical trials, observational studies (cohort or case-control).
Exclusion criteria were as follows: Irrelevant articles, editorials, letters, case reports, reviews, and meta-analyses. Studies with fewer than three patients or those combining the investigated techniques with other surgical methods were also excluded. Articles containing duplicate data or not explicitly reporting the primary outcomes of this review were excluded.
Study selection and data extraction
Two reviewers (ZL and LJ) independently performed the selection and extraction processes. Disagreements were resolved with the senior investigators (JW and PCA). The first step involved screening titles and abstracts by both researchers to identify potentially eligible articles. Furthermore, the reference lists of eligible studies were manually searched for additional potential articles. Duplicate records were removed. Finally, full texts were independently assessed for eligibility by the two researchers, with inconsistencies resolved through discussion with PCA and JW.
Data analysis and synthesis
Statistical analysis was performed using Stata software. For dichotomous variables (e.g., healing rate, recurrence rate), risk ratios (RR) and 95% confidence intervals (CI) were calculated. For continuous data, the chi-square test and I² statistic were used to assess heterogeneity and determine the consistency of results across different studies.
Results
Search results
A total of 326 articles were retrieved from the databases. After removing duplicates and screening titles and abstracts, 29 studies met the inclusion criteria and were finally included in this meta-analysis [6, 7, 11–37]. The detailed literature screening process is shown in Fig. 1.
Fig. 1.
Flow chart of the systematic review
Characteristics of the included studies
Overall, this review included 19 studies on SiLaC and 10 studies on EPSiT. The basic characteristics of these studies are presented in Table 1.
Table 1.
Characteristics of the included studies
| Author year | Type of article | Period | Country | n | Treatment | Main outcomes | |
|---|---|---|---|---|---|---|---|
| Tran,2025 | retrospective | December 2024 to July 2025 | PSD | Vietnam | 9 | SiLaC | Operative time, complications rate, healing time, healing rate, recurrence rate |
| EMRAL, 2025 | retrospective | January 2022 and January 2025 | recurrent PD | Turkey | 37 | SiLaC | Healing rate, recurrence rate, complications rate |
| Romanova,2024 | retrospective | 2019 to 2023 | PD | Germany | 17 | SiLaC | Recurrence rate, complications rate, operative time |
| Yildirim,2024 | retrospective | March 2020 to December 2023 | PD | Turkey | 64 | SiLaC | Recurrence rate, complications rate, healing rate |
| Sharaf,2024 | retrospective | March 2022 to June 2022 | PD | Egypt | 30 | SiLaC | Recurrence rate, complications rate |
| Kalaitzis,2024 | retrospective | January 2018 to January 2024 | PD | - | 368 | LaPSe | Healing rate, recurrence rate, complications rate |
| Al-Khazraji,2024 | prospective | February 2023 and February 2024 | PSD | Iraq | 50 | SiLaT | Complications rate |
| GÜLEN,2024 | retrospective |
August 2020 and August 2023 |
PSD | Turkey | 49 | SiLaC | Complications rate, recurrence rate |
| Horesh,2023 | retrospective | September 2018 and December 2020 | PSD | Israel | 92 | SiLaC | Healing rate, recurrence rate |
| Pappas,2018 | prospective | June 2012 to December 2015 | PSD | Greece | 237 | SiLaT | Healing rate, Complications rate |
| Li,2023 | retrospective | March 2019 and July 2022 | SPD | China | 48 | Silac | Healing rate, recurrence rate, operative time, healing time |
| Johnson,2022 | prospective | April 2016 and July 2019 | PSD | UK | 35 | PiLAC | Healing rate, recurrence rate, |
| Hinksman,2023 | Retrospective | January 2014 to November 2019 | PSD | Australia | 137 | EPSIT | Return to work, Return to work, pain |
| Erculiani,2022 | retrospective | January 2017 and December 2021 | PSD | Italy | 115 | EPSiT | Recurrence rate |
| Zubaid,2022 | retrospective | February 2012 to December 2019 | PSD | SAU | 41 | SiLaT | Complications rate, healing time, recurrence rate |
| Sluckin,2022 | cohort | January 2017 to March 2020 | PSD | The Netherlands | 311 | SiLac | Recurrence rate, complications rate |
| Foti,2021 | retrospective | March 2015 to December 2019 | PSD | Italy | 42 | EPSiT | Operative time, complications rate, healing time, recurrence rate, healing rate |
| Bonito,2021 | retrospective | July 2018 to August 2020 | PSD | Portugal | 27 | SiLac | Healing rate, recurrence rate, complications |
| Spindler,2021 | retrospective | June 2018 to August 23 2019 | PSD | France | 29 | SiLac | Healing rate, healing time, complications rate |
| Dotlacil,2021 | retrospective | November 2018 to February 2020 | PSD | Czech | 17 | EPSiT | Complications rate, recurrence rate |
| Gulcu,2021 | prospective | May 2018 to December 2019 | PSD | Turkey | 86 | EPSIT | Operative time, complications rate, healing time |
| Manigrasso,2020 | Retrospective | January 2014 to December 2018 | recurrent PSD | Italy | 63 | VAAPS | Recurrence rate, healing time |
| Dessily,2019 | Retrospective | March 2015 to August 2017 | PSD | Belgium | 200 | SiLac | Healing rate, healing time, operative time, recurrence rate, complications rate |
| Meinero,2019 | prospective | March 2012 to December 2014 | recurrent PSD | Italy | 122 | EPSIT | Healing rate, healing time, |
| Georgiou,2018 | prospective | April 2015 and December 2016 | PSD | Greece | 60 | PiLaT | Satisfaction, success rate, VAS pain scores |
| Prato,2018 | prospective | July 2015 and March 2017 | PSD | Italy | 43 | EPSiT | Recurrence rate, complications rate, healing rate |
| Dessily,2017 | retrospective | September 2014 and September 2015 | PSD | Belgium | 40 | SiLac | Healing rate, recurrence rate, complications rate |
| Giarratano,2017 | prospective | October 2013 through November 2015 | PSD | Italy | 77 | EPSiT | Operative time, healing rate |
| Meinero,2016 | prospective | March 2012 to December 2014 | PSD | Switzerland, | 250 | EPSiT | Healing rate, healing time, recurrence rate |
Risk of bias evaluation
The methodological quality of the studies was assessed independently by two authors (ZL and LJ) using the National Institute for Health and Care Excellence (NICE) quality assessment checklist for case series. Any discrepancies in interpretation were resolved through discussion with the third author (JW). Study quality was categorized as good (score = 7–8), moderate (score = 4–6), or poor (score = 0–3). The results are summarized in Table 2.
Table 2.
Assessment of the methodological quality of studies included in the review
| Study | Multicenter study | Clearly defined objective | Reported inclusion and exclusion criteria | Clearly defined outcomes | Prospective data collection | Patients recruited consecutively | Clearly described results of the study |
Stratified outcomes | Total score |
|---|---|---|---|---|---|---|---|---|---|
| Tran,2025 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| EMRAL, 2025 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Romanova,2024 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Yildirim,2024 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Sharaf,2024 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Kalaitzis,2024 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Al-hazraji,2024 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 |
| GÜLEN,2024 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Horesh,2023 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Pappas,2023 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 |
| Li,2023 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Johnson,2022 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 |
| Hinksman,2023 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Erculiani,2022 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Zubaid,2022 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Sluckin,2022 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Foti,2021 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Bonito,2021 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Spindler,2021 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Dotlacil,2021 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Gulcu,2021 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 |
| Manigrasso,2020 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Dessily,2019 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Meinero,2019 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 |
| Georgiou,2018 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 |
| Prato,2018 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 |
| Dessily,2017 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 6 |
| Giarratano,2017 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 |
| Meinero,2016 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 |
Operation time
Regarding operation time, the mean lengths of surgery for SiLaC was 18.02 min (95% CI: 13.42–22.62; I2 = 99.4%; P < 0.001), Fig. 2, and 30.11 min for EPSiT (95% CI: 21.33–38.88; I² = 98.5%; P < 0.001), Fig. 3.
Fig. 2.
Forest plots of operation time in laser therapy group
Fig. 3.
Forest plots of time in endoscopic treatment group
Cure rate
The pooled cure rate of SiLaC was 86% (95% CI: 80–91%; I2 = 92%; P < 0.001), Fig. 4. For EPSiT the pooled cure rate was 88% (95% CI: 83–94%; I² = 87.1%; p < 0.001), Fig. 5.
Fig. 4.
Forest plots of cure rate for SiLaC
Fig. 5.
Forest plots of cure rate in endoscopic treatment group
Recurrence rate
The rate of recurrence was 11% for SiLaC (95% CI: 6–15%; I² = 90.4%; p < 0.001), Fig. 6 and 9% for EPSiT (95% CI: 5–12%; I² = 82.9%; P < 0.001), Fig. 7.
Fig. 6.
Forest plots of recurrence rate for SiLaC
Fig. 7.
Forest plots of recurrence rate for EPSiT
Complication rate
The complication rate was 9% for SiLaC (95% CI: 6–12%; I² = 74.6%; p < 0.001), Fig. 8 and 7% for EPSiT (95% CI: 1–15%; I² = 74.7%; P < 0.05), Fig. 9.
Fig. 8.
Forest plots of complication rate in laser therapy group
Fig. 9.
Forest plots of complication rate in endoscopic treatment group
Healing time
The mean time to complete healing was 30.08 days (95% CI: 25.86–38.19; I² = 98.6%; P < 0.001) after SiLaC, Fig. 10 and 26.55 days (95% CI: 24.40–28.70; I² = 90.9%; P < 0.001) after EPSiT, Fig. 11.
Fig. 10.
Forest plots of healing time in laser therapy group
Fig. 11.
Forest plots of healing time in endoscopic treatment group
Discussion
Both laser therapy and endoscopic treatment are well-established minimally invasive surgical modalities for pilonidal sinus disease in recent years [11, 12, 25, 37, 38]. Although both procedures are being increasingly adopted for the management of patients with PSD little or no data on comparisons of both interventions exist in the current literature. The aim of this systematic review and meta-analysis was to fill this gap in the literature. The current literature is void of publications with direct comparisons between SiLaC and EPSiT. Thus, meta-analysis with direct comparison of both interventions could not be performed.
A cohort study by Ersavas et al. involving 73 patients undergoing either SiLaC or EPSiT demonstrated no statistically significant differences in terms of recurrence rate, operative time, complication rate, wound healing time, and time to return to normal daily activities [20], largely supporting the results reported in this study.
Although direct comparison of the results of the two procedures is not feasible due to lack of studies directly comparing both procedures, the pooled results indicated that laser therapy and endoscopic treatment yielded comparable cure rates, recurrence rates and complication rates. The duration of surgery represents the only difference identified amongst both interventions. Although SiLaC was relatively faster compared to EPSiT, the confidence interval (CI) of the SiLaC group was overall much lower than the estimated value of the EPSiT group. However, the CIs of the two interventions slightly overlap at the edge. This finding suggested that while SiLaC may be a slightly faster procedure, EPSiT may have a similarly short duration of surgery in very experienced hand.
While a visualized exploration of the sinus tract to avoid missing branches and the possibility of a complete destruction of granulation tissue and radical debridement under visual guidance have been thought as advantages of EPSiT, these argumentations remain debatable from a clinical standpoint. First, these aspects inevitable prolong the duration of surgery. Second, the endoscopic procedure requires not only investing in specialized equipment, but also demand for additional training. Therefore, the endoscopic procedure is associated with a higher treatment cost compared to the SiLaC alone [25]. It is therefore questionable whether or not the cost incurred by the endoscopic technique is justified by the 4 days difference in complete wound healing, as this seems to be the only positive difference between SiLaC and EPSiT. This critical thinking is back by the results from the study by Bilgin et al. reporting on 106 patients undergoing minimally invasive treatment for PSD, including 73 cases with a combination of Laser and EPSiT. The study failed to show any significant benefits in postoperative outcomes, including no obvious improvements in pain, recovery time, complication rate, readmission rate, recurrence rate and patient satisfaction [39]. Contrary to the data published by Bilgin et al., Mustapha Ouali reported a 95% rate of complete epithelialization within 3 weeks and 3.3% recurrence rate at 6 month using the combination of SiLaC and EPSiT [10]. A similar finding was reported by Gulcu et al. for wound healing following combined Laser and EPSiT [25]. Although the literature on this topic is not conclusive and hardly any consistent patterns were observed, experts from the International Society of Laser Proctology (ISoLP) acknowledge some advantages of combining SiLaC with EPSiT, which has been termed E-SiLaC. In their recently published position paper on SiLaC and EPSiT, ISoLP suggests an individualized assessment of patients to identify candidates who may benefit from E-SiLaC [10].
Limitations
Some relevant limitations to this study need to be discussed. First, direct comparison between both interventions was not possible due to lack of studies. Thus, a single intervention meta-analysis was performed for each treatment arm. Second, all studies included in this systematic review are of retrospective design with well - known limitations, small sample sizes, short follow-up durations and heterogeneity of available data limit the precision and interpretability of the pooled estimates reported in this work. Third, variability in surgical techniques across different centers with subsequent heterogeneity in outcomes may have influenced the overall results seen in this study. Forth, there is a possibility that some potentially eligible studies were not identified using our search strategy. Finally, a formal cost-effectiveness analysis was beyond the scope of this review, but the economic implications of equipment, operative duration, and time to return to work constitute an important area for future comparative research.
Conclusion
Based on current evidence, SiLaC and EPSiT are effective minimally invasive treatments for PSD, with comparable healing and recurrence rates. The selection of surgical modality should be individualized, comprehensively considering equipment availability, surgeon proficiency, and patient preference.
Author contributions
PCA and JW concepted the studyJL , ZL, ZW performed the literature search, data extractionZL and JL performed data extractionJL, ZL, ZW and JW performed data analysisZL and JL drafted the ManuscriptPCA, MO JU and VdP critically reviewed and revised the manuscript.All authors approved the final version.
Funding
Open Access funding enabled and organized by Projekt DEAL.
Data availability
All data besides what is published can be requested via the corresponding authors.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Jiong Wu and Peter C. Ambe are Equal senior and corresponding authors
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Zhicheng Li and Lei Jin contributed equally to this work.
Contributor Information
Jiong Wu, Email: tcmoctober9@163.com.
Peter C. Ambe, Email: peter.ambe@uni-wh.de
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Data Availability Statement
All data besides what is published can be requested via the corresponding authors.