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Francesco Mongelli,1 Massimo Lucchelli,2 Davide La Regina,3 Dimitri Christoforidis,1 Andrea Saporito,4 Alberto Vannelli,5 Matteo Di Giuseppe3 1Department of Surgery, Ospedale Regionale di Lugano, Lugano, Switzerland; 2Financial Department, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 3Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 4Department of Anesthesia, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 5Department of Surgery, Ospedale Valduce, Como, ItalyCorrespondence: Francesco MongelliOspedale Regionale di Lugano, via Tesserete 46, Lugano, 6900, SwitzerlandTel +41764706297Fax +41918119066Email francesco.mongelli@mail.comBackground: Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy.Methods: From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed.Results: Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482± 386 vs 613± 543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606± 816 vs 2769± 1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of − 243 ± 881 EUR/pain unit on the VAS.Conclusion: Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.Keywords: pudendal nerve, nerve block, cost-benefit analysis, postoperative pain, hospital costs