Background: Hemorrhoids significantly impact quality of life and healthcare costs. While rubber band ligation and hemorrhoidectomy are common treatments for grade III hemorrhoids, comparative cost-effectiveness data are limited.

Objective: To assess the cost-effectiveness and cost-utility of rubber band ligation compared to hemorrhoidectomy from a societal perspective within the context of the HOLLAND trial.

Methods: Cost-effectiveness and cost-utility analyses using data from a multicenter, randomized controlled trial. Methods: Ten Dutch hospitals participating in the HOLLAND trial. Methods: Adults with symptomatic grade III hemorrhoids randomized to rubber band ligation or hemorrhoidectomy. Methods: Rubber band ligation (up to two sessions) or excisional hemorrhoidectomy. Methods: Cost per quality-adjusted life year (QALY) gained and cost per recurrence avoided over 24 months from a societal perspective.

Results: Seventy-nine patients were analyzed (33 hemorrhoidectomy, 46 rubber band ligation). Hemorrhoidectomy resulted in better clinical outcomes with a QALY difference of 0.08 (95% CI, 0.04-0.13) and a recurrence difference of 33.5% (95% CI, 15.3%-51.7%). Hospital costs were higher for hemorrhoidectomy (€1,364; 95% CI, 895-1,834; p < 0.001), as were societal costs (€1,984; 95% CI, -132-4,101; p = 0.066). The incremental cost-utility ratio for hemorrhoidectomy was €24,042 per QALY gained, and the incremental cost-effectiveness ratio was €5,918 per recurrence avoided. The probability of hemorrhoidectomy being cost-effective was 45.5% at €20,000/QALY and 83.9% at €50,000/QALY. For recurrence avoidance, probabilities were 98.3% and 99.8%, respectively.

Conclusions: The small sample size may limit generalizability and the ability to detect rare but costly complications. Procedural costs were based on average hospital prices, which is a pragmatic approach, though less detailed than bottom-up costing. Conclusions: In patients with grade III hemorrhoids, hemorrhoidectomy provides better long-term clinical outcomes, including higher quality of life and lower recurrence rates compared to rubber band ligation. However, its cost-effectiveness varies depending on societal willingness-to-pay thresholds. Caution is warranted before discarding it as a first-line treatment based solely on healthcare costs or limited operating room availability. See Video Abstract.Clinical Trial Registration Number: NCT04621695.