Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d3182236e249">Background</h5> <p id="P1">Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d3182236e254">Methods</h5> <p id="P2">A meta-analysis of the literature was conducted using PubMed, EMBASE and Cochrane databases through September 2016 in accordance with PRISMA guidelines. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d3182236e259">Results</h5> <p id="P3">Seventy case series that reported GTR rate in 8257 pituitary adenomas patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I <sup>2</sup>=92.1%) was associated with higher GTR as compared to mTSS (GTR=66. <b>4</b>%; I <sup>2</sup>=84.0%) in a fixed-effect model (P-interaction<0.01). For functioning pituitary adenomas (FPAs) (n=1,170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I <sup>2</sup>=63.9%) and mTSS (GTR=75.5%; I <sup>2</sup>=79.0%); (P-interaction=0.92). For non-functioning pituitary adenomas (NFPAs) (n=2,655 patients), eTSS (GTR=71.0%; I <sup>2</sup>=86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I <sup>2</sup>=87.5%) in a fixed-effect model (P-interaction<0.01). None of the associations were significant in a random-effect model (all P-interaction>0.05). No significant publication bias was identified for any of the outcomes. </p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d3182236e286">Conclusion</h5> <p id="P4">Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be stated with caution because of the nature of the included non-comparative studies. </p> </div>

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Transsphenoidal surgery for pituitary tumors in the United States, 1996-2000: mortality, morbidity, and the effects of hospital and surgeon volume.

Fred G Barker, Anne Klibanski, Brooke Swearingen (2003)

Larger surgical caseload is associated with better patient outcome for many complex procedures. We examined the volume-outcome relationship for transsphenoidal pituitary tumor surgery using the Nationwide Inpatient Sample, 1996-2000. Multivariate regression adjusted for patient demographics, acuity measures, medical comorbidities, and endocrine status. A total of 5497 operations were performed at 538 hospitals by 825 surgeons. Outcome measured at hospital discharge was: death (0.6%), discharge to long-term care (0.9%), to short-term rehabilitation (2.1%), or directly home (96.2%). Outcomes were better after surgery at higher-volume hospitals (OR 0.74 for 5-fold-larger caseload, P = 0.007) or by higher-volume surgeons (OR 0.62, P = 0.02). A total of 5.4% of patients were not discharged directly home from lowest-volume-quartile hospitals, compared with 2.6% at highest-volume-quartile hospitals. In-hospital mortality was lower with higher-volume hospitals (P = 0.03) and surgeons (P = 0.09). Mortality rates were 0.9% at lowest-caseload-quartile hospitals and 0.4% at highest-volume-quartile hospitals. Postoperative complications (26.5% of admissions) were less frequent with higher-volume hospitals (P = 0.03) or surgeons (P = 0.005). Length of stay was shorter with high-volume hospitals (P = 0.02) and surgeons (P < 0.001). Hospital charges were lower for high-volume hospitals, but not significantly. This analysis suggests that higher-volume hospitals and surgeons provide superior short-term outcomes after transsphenoidal pituitary tumor surgery with shorter lengths of stay and a trend toward lower charges.

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Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series.

Konstantina Karabatsou, Ali Dehdashti, Fred Gentili … (2008)

The aim of this study was to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach and to evaluate the efficacy and safety of this procedure. We reviewed 200 consecutive patients with pituitary adenoma who underwent purely endoscopic transsphenoidal resection of their lesions. The patients' clinical outcomes, including remission rates, degrees of tumor removal, and complications, were evaluated and compared with a previous microscopic series. There were 111 nonfunctioning adenomas and 34 growth hormone-secreting, 27 adrenocorticotropin hormone-secreting, 25 prolactin-secreting, and 3 thyroid-stimulating hormone-secreting adenomas. The degree of gross total removal for tumors with suprasellar or parasellar extension and without cavernous sinus involvement was 96% and for intrasellar lesions was 98%. After a median follow-up period of 19 months, the remission results for patients with functioning adenomas were 71% for growth hormone-secreting, 81% for adrenocorticotropin hormone-secreting, and 88% for prolactin-secreting adenomas, with no recurrence at the time of the last follow-up. This compares with similar results reported from series using a standard microsurgical approach (growth hormone-secreting adenomas, 67%; adrenocorticotropin hormone-secreting adenomas, 78%; and prolactin-secreting adenomas, 62%). Endoscopic surgery for recurrent or residual nonfunctioning adenomas that had been previously treated using a microscopic approach revealed in the majority of cases a more limited exposure during the initial surgery, frequently with incomplete tumor removal. Complication rates have been low, and the average length of hospital stay was reduced. A purely endoscopic approach for pituitary adenoma treatment is a safe and effective alternative to the traditional microscopic procedure. Although our results reveal excellent tumor-removal rates, comparable remission rates in functioning tumors, and a very low rate of complications, additional studies with longer follow-up periods are required to confirm whether this approach should be considered the preferred procedure for pituitary surgery.

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Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas.

Luigi Cavallo, Enrico De Vita, Paolo Cappabianca … (2002)

To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary adenomas between January 1997 and July 2001. Complications were divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma. Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.