Endoscopic Pilonidal Sinus Treatment Versus Excisional Surgery: A Retrospective Comparison at an Australian Tertiary Centre

BACKGROUND: Endoscopic pilonidal sinus treatment (EPSiT) may reduce recovery burden, but comparative data against contemporary excisional practices in Australia are limited. METHODS: We conducted a retrospective cohort study of consecutive elective pilonidal operations in patients aged ≥ 12 at a tertiary Australian hospital (January 2018-May 2025). Analyses were performed at the operative episode level, including repeat procedures. EPSiT was compared with excisional surgery (off-midline flap closure, lay-open excision or primary closure). The primary outcomes were primary healing and recurrence after healing. Secondary outcomes were same-day discharge and opioid prescription at discharge. RESULTS: The cohort included 180 elective operative episodes in 144 patients: 115 EPSiT (63.9%) and 65 excisional (36.1%). Primary healing occurred in 158 episodes (87.8%) and did not differ between EPSiT and excision (89.6% vs. 84.6%; p = 0.330). Recurrence occurred in 26.6% and was similar between groups (29.1% vs. 21.8%; p = 0.322). EPSiT was associated with higher same-day discharge (86.1% vs. 21.5%; p < 0.001) and lower opioid prescribing at discharge (2.6% vs. 63.1%; p < 0.001). In the subgroup with prior emergency I&D (n = 66), primary healing remained similar (89.5% vs. 85.7%; p = 0.644), but recurrence after healing was higher following EPSiT (47.1% vs. 20.8%; p = 0.041). CONCLUSIONS: EPSiT achieved similar primary healing and recurrence to excisional surgery while enabling ambulatory care and opioid-sparing discharge. Prior abscess I&D was associated with higher recurrence after EPSiT despite comparable primary healing, supporting tailored counselling and selective EPSiT use when long-term durability is prioritised.