Aim: The optimal surgical technique for pilonidal sinus disease (PSD) remains controversial. This propensity score-matched study compared trephination with wide local excision to minimize selection bias.

Methods: We retrospectively analyzed 317 patients undergoing surgical treatment for PSD (2010-2022). Propensity score matching (1:1, caliper 0.05) using age, sex, body mass index (BMI), occupation, smoking, previous surgery, and symptom duration yielded 78 matched pairs. Primary outcome was recurrence; secondary outcomes included pain [Visual Analog Scale (VAS)], healing time, hospital stay, and return to work. Multivariate logistic regression identified recurrence predictors.

Results: After matching, groups were well-balanced [all standardized mean differences (SMDs) < 0.2]. Recurrence occurred in 15.4% of excision versus 7.7% of trephination patients (P = 0.20). Trephination demonstrated significantly lower pain scores at all timepoints: day 1 (5.2 ± 0.6 vs. 6.3 ± 1.7), day 7 (1.5 ± 1.1 vs. 2.8 ± 1.2), and month 1 (0.1 ± 0.2 vs. 0.5 ± 0.5; all P < 0.001). Hospital stay (1.0 ± 0.7 vs. 2.3 ± 1.2 days) and return to work (10.5 ± 2.2 vs. 12.7 ± 6.4 days) were shorter with trephination (both P < 0.001). Multivariate analysis identified younger age [odds ratio (OR) 0.46 per standard deviation (SD) increase of ~ 10-11 years; P = 0.005] and higher BMI (OR 1.60 per 1 kg/m² increase; P = 0.03) as independent predictors of recurrence.

Conclusions: Trephination offers significant advantages in postoperative pain, hospital stay, and return to work compared to wide local excision, with a favorable but non-significant difference in recurrence. These findings support trephination when rapid recovery is prioritized. Larger trials are needed to establish long-term recurrence equivalence.