Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal

TLDR

Total removal of nonfunctioning pituitary adenomas is difficult because of their size and lateral extension, leading to frequent postoperative remnants; endoscopy improves surgical visualization but its superiority in outcomes remains uncertain. The study compared clinical outcomes and morbidity between microscopic and endoscopic approaches in 164 patients with nonfunctioning pituitary adenomas. Patients were divided into two groups of 82 each, undergoing either a sublabial microscopic or a fully endonasal endoscopic procedure, with tumor characteristics assessed by 3‑D MR imaging and clinical, endocrinological, and ophthalmological outcomes recorded. One year postoperatively, the endoscopic group achieved a higher gross‑total resection rate (74% vs 50%) and better control of lateral and suprasellar extension, improved endocrinological outcomes in patients with pre‑operative anterior pituitary deficiency, and similar morbidity compared with the microscopic group, confirming that endoscopy improves resection quality and endocrine recovery.

Abstract

Because of their size and lateral extension, total removal of nonfunctioning pituitary adenomas (NFPAs) remains a challenge and postoperative tumor remnants are frequent. Endoscopy has improved the surgeon's view; however, its superiority in terms of surgical outcome remains undetermined. The authors' aim in this study was to compare the clinical results and morbidity between microscopic and endoscopic techniques in 164 patients with NFPAs.Tumoral (3D MR imaging), endocrinological, and ophthalmological results and morbidity were compared between 2 groups of 82 patients with newly diagnosed NFPAs surgically treated via either a sublabial microscopic approach (Group B) or a fully endonasal endoscopic technique (Group A).The groups showed no difference in terms of clinical features, tumor size, or cavernous sinus invasion (p > 0.05). One year postoperatively, the quality of resection was significantly improved in Group A (gross-total removal [GTR]: 74% vs 50% in Group B, p = 0.002) with greater control of lateral extension (Knosp Grade 2: GTR 88.2% vs 47.8% in Group B, p = 0.02; Knosp Grade 3: 67.9% vs 16.7% in Group B, p < 0.001) and suprasellar extension (tumor height 20-30 mm: GTR 76% vs 53% in Group B, p = 0.01). Endocrinological outcome in patients with a partial deficiency in anterior pituitary function preoperatively was significantly better in Group A (improvement 56% vs 25% in Group B, stabilization 22% vs 46%, and aggravation 22% vs 29%; p = 0.01). Among the ophthalmologically symptomatic patients, 100% from Group A improved compared with 93% in Group B (p = 0.35). Lastly, no significant difference was found regarding morbidity. These data were supported by the literature in which the GTR rate is consistently higher for endoscopy compared with microscopy.In this large series of patients with NFPAs, endoscopy improved the quality of resection and endocrinological outcome. Larger studies focusing on the impact of these promising results on the long-term recurrence of NFPAs are warranted.