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What is the Rafaelo procedure?
The Rafaelo Procedure (Radiofrequency Treatment of Haemorrhoids under Local Anaesthesia) is a novel treatment for haemorrhoids.
The concept of applying radiofrequency energy to haemorrhoids was adapted from vascular surgery, where surgeons have been treating varicose veins under local anaesthetic with radiofrequency energy for several years with excellent clinical outcomes. Haemorrhoids are enlargements of the anal cushions, which consist of networks of interconnecting arteries and veins – hence they are vascular structures similar to varicose veins.
On arrival at the clinic, you will have a full clinical assessment. Your consultant will take a careful history and perform a clinical examination including a proctoscopy, where a small plastic telescope is inserted into the back passage to characterise the size, location and composition (internal vs. external) of the haemorrhoids and exclude any other anal pathology. You will then be advised whether your haemorrhoids are suitable for treatment with the Rafaelo procedure. If they are, you can proceed to treatment during the same consultation. If they are not, you will be advised on what other treatments are available.
Most people are able to tolerate the Rafaelo procedure with local anaesthetic only. It can also be performed whilst giving you Entonox (‘laughing gas’, often given to women for pain relief during labour). For people who find being examined in the anal area very uncomfortable, the procedure can also be performed under light sedation or even under general anaesthetic – in this case, a second visit to One Welbeck would be required in order to allow for adequate planning and preparation.
You will lie on your left hand side. The standard proctoscope will be changed to a special proctoscope with a small side window, which allows the haemorrhoid to bulge into the anal canal. A small amount of local anaesthetic will then be injected under the haemorrhoid to protect the underlying anal sphincter muscle. The Rafaelo energy probe is then inserted into the haemorrhoid and radiofrequency energy will be applied. As the energy is applied, the haemorrhoidal tissue heats up. You will feel an odd sensation of discomfort as the energy is applied, but no significant pain. If a small amount of pain is felt, this means that the tissues are heating up a little too much. When this occurs, it is important that you tell your surgeon about this. They will then stop applying the radiofrequency energy and cool down the area with cold saline. Once the area has been cooled down, more energy can be applied safely.
Why is it performed?
Haemorrhoids have both internal and external components. The internal components are above an anatomical landmark called the dentate line. This distinction is important, because the body can’t feel pain above the dentate line, hence the internal components of haemorrhoids can be heated up and coagulated by the radiofrequency energy without causing significant pain. It is also important to appreciate that the external, skin-covered components of haemorrhoids cannot be treated with radiofrequency energy. However, when the internal components shrivel up after the Rafaelo procedure, they usually pull the external components up and back into the anal canal, making them much smaller and less symptomatic.
What are the benefits?
This procedure is an office based procedure that does not require a general anaesthetic. It causes less pain than operative procedures to remove haemorrhoids and therefore the recovery is much faster.
What are the risks?
1. Bleeding: A small amount of rectal bleeding (less than an eggcupful a day) or spotting is common and normal in the first 2 weeks after the procedure. Around 4 in 100 people experience significant rectal bleeding after the procedure. This can occur either in the first 48 hours or in a delayed fashion after 10 – 14 days. This is because the clot that forms over the puncture site on the haemorrhoid where the Rafaelo probe has entered can fall off. If you bleed heavily (i.e. more than a cupful, around 200 mL, in a 24 hour period) at any point after the procedure, please contact One Welbeck Street during office hours or your local A&E Department out of hours.
2. Pain: In the rare event that you get pain that is not controlled by paracetamol or ibuprofen, please contact One Welbeck Street or your GP during office hours. Out of hours, please contact or your local A&E Department. You may need to be prescribed additional painkillers.
3. Urgency: Feeling an urgent need to visit the toilet to open your bowels, not necessarily resulting in producing a stool, can last for up to 48 hours after the procedure. This settles down by itself.
4. Infection: This has not been reported commonly after the procedure, but can occur in theory. If you develop a temperature of more than 38 degrees Celcius in the first two weeks after the procedure, please contact One Welbeck Street during office hours or your local A&E Department out of hours.
5. Anal fissure: Rarely, people can develop an anal fissure (a superficial tear in the skin lining the anal canal) after procedures for haemorrhoids. This has not been officially reported after the Rafaelo procedure so far. If a fissure occurs, the symptomatic hallmark is severe pain in the anus on opening your bowels and sometimes a small amount of bright red bleeding.
What are the alternatives?
Haemorrhoids can be treated with a number of alternative treatments including rubber band ligation or a procedure where stitches are placed under ultrasound guidance in the blood vessels that supply the haemorrhoid. Ultimately the haemorrhoid can also be completely removed.
What is the recovery like?
The procedure will take between 5 and 15 minutes depending on the size of your haemorrhoids. Afterwards, you will feel some minor discomfort in the back passage. Some people feel a small amount of pain, which can necessitate taking paracetamol or ibuprofen. Expect to feel some urgency of defaecation for 48 hours after the procedure. The urgency occurs because the autonomic nerves in the back passage are stimulated by the radiofrequency energy. When you get urgency, your brain receives a signal from the back passage suggesting that you need to open your bowels. Often, people then need to visit the loo in a hurry, only to find that they are unable to produce a stool. This is because the back passage is in fact empty, but the nerves think that a stool is on its way. As time passes, the autonomic nerves calm down and the urgency goes away, usually after the first two days.
After the procedure, you will be able to go home. You can drive and go on public transport unaccompanied if you have had the procedure under local anaesthetic. Most people do not need to take any painkillers afterwards, but you should make sure that you have some paracetamol and ibuprofen available at home in case you feel a small amount of pain. You might see a small amount of blood (an eggcupful or less) in the toilet the first time you open your bowels after the procedure – this is normal and nothing to worry about.
You will be offered a follow-up appointment 4 weeks later to check that you are satisfied with the outcome of the treatment. It is important to allow this time to pass before reassessment, as the radiofrequency energy continues to work for the first two weeks, causing the haemorrhoids to shrink further in the initial recovery stages.
Frequently Asked Questions
1. Will I be able to work the next day?
Most people are able to work the following day. However, if you get urgency this can be a little unpredictable, so if you have the option of working from home, it is advisable to do this on the first day.
2. Do I need to change my diet around the procedure?
You do not need to fast before the procedure. You can continue eating and drinking as you normally would before and after the procedure, but we advise that you increase the amount of fibre in your diet and your fluid intake in the first two weeks after the procedure to avoid constipation.
3. What if I get pain?
Take 2 tablets (1000 mg) of paracetamol every 4 to 6 hours. If this is not sufficient, add in 2 tablets (400 mg) of ibuprofen every 4 to 6 hours. You can take both painkillers together safely. Some people have contraindications to ibuprofen – check with your surgeon on the day or with your doctor or pharmacist.
4. Will I be able to open my bowels?
You will be able to open your bowels normally. This should not be more painful than normal. As mentioned above, you may experience urgency of defaecation.
5. Can I have sex after the procedure?
You can have sex normally after the procedure.
6. Does the Rafaelo procedure work for everyone?
We find that, in practice, 9 out of 10 people are satisfied with the outcome of the procedure. 1 in 10 feel that their symptoms are not improved sufficiently afterwards. In these cases, the Rafaelo procedure can be repeated, or an alternative treatment like excision of remaining anal skin tags or traditional haemorrhoidectomy may be required. Your Consultant will advise you on this when you attend for the follow-up consultation.