Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 24-32
World Neurosurgery

Original Article
Quality of Life and Work Capacity Are Unrelated to Approach or Complications After Pituitary Surgery

https://doi.org/10.1016/j.wneu.2017.08.087Get rights and content

Objective

Endoscopic pituitary surgery has shown favorable clinical outcomes. Less is known about the impact of surgical approaches on health-related quality of life (HRQoL) and work capacity. The present study was undertaken to compare transsphenoidal microscope-assisted surgery with endoscopic transsphenoidal surgery regarding preoperative and surgical factors for the final outcome of HRQoL and work capacity.

Methods

In a retrospective study of patients operated on for pituitary adenoma, outcome was compared between those operated on before and after transition with endoscopic surgery at our department. Data were gathered via patient questionnaires and patients' files.

Results

After exclusions, 235 patients were included (99 microsurgical and 136 endoscopic). Frequency of complications was similar but tumor size was significantly larger in the endoscopic group. Complications did not affect HRQoL or work capacity. HRQoL was not affected by surgical technique but showed an overall trend toward lower values compared with the general population. Sick leave, return to work frequency, and permanent sick leave were not affected by surgical technique. Female gender was a factor for lower ratings in all outcome variables.

Conclusions

Surgical technique does not influence HRQoL or work capacity in this long-term follow-up although both are decreased compared with the general population. We conclude that fully endoscopic pituitary surgery, despite including larger tumors, bears the same risk for complications as microsurgery. In addition, females have a greater risk for decrease in HRQoL and work ability. This factor should be taken into account when informing patients and appreciating expectations of treatment.

Introduction

In contrast to the introduction of new drugs in clinical medicine, the launch of new surgical techniques is seldom preceded by prospective clinical trials. Instead, surgical techniques are mostly evaluated after their introduction and then compared with previous techniques regarding medical effectiveness and cost efficiency.1 Evaluations often focus on conventional outcome factors such as resection rate, recurrence, or complications.2, 3, 4, 5 The introduction of purely endoscopic transsphenoidal pituitary surgery has been evaluated in various studies, often showing comparable rates of gross total resection, lower incidence of complications, shorter hospital stay, and shorter time of surgery compared with microsurgical transsphenoidal surgery, but some studies have been neutral.2, 3, 4, 6, 7, 8 No randomized trials have been initiated.

During recent years, the patient's perspective after different therapies has come into focus with the development of the health-related (HR) quality of life (QoL) concept.9 Both generic scales (e.g., EQ-5D, Short-Form 3610, 11) and disease-specific scales (e.g., AcroQoL for acromegaly and the Anterior Skull Base Nasal Inventory 12 evaluating nasal QoL after endonasal surgery) have been used for patients with pituitary adenomas and for endoscopic pituitary surgery.12, 13, 14 HRQoL is reported to be affected in all subgroups of pituitary adenomas and is often significantly decreased also after what is considered successful surgical treatment.15, 16, 17, 18 Surgical treatment of pituitary adenomas can cause a decreased HRQoL by, for example, causing hypopituitarism, optic nerve damage, or injury to other neural structures. In addition, the transsphenoidal route can cause nasal morbidity such as crusting, bleeding, and decreased olfactory function, which at least in the shorter perspective, causes or adds to a decreased HRQoL.19, 20, 21 Decreased HRQoL is expected to cause decreased work capacity, which can be measured by changes in work ability. Work capacity has the advantage of being biased by neither the health providers or the patient's views but has the disadvantage of not being meaningful in retired or unemployed patients.

Data on the impact of different surgical approaches to pituitary adenomas on HRQoL and work capacity are scarce. Therefore, the present retrospective study was undertaken to compare transsphenoidal microscope-assisted pituitary surgery to a purely endoscopic transsphenoidal approach with regard to preoperative findings and surgical factors for the final outcome of generic HRQoL and work capacity.

Section snippets

Patients

All procedures were performed at the Department of Neurosurgery, Skåne University Hospital, Lund, Sweden, which is a tertiary referral center for 1.7 million inhabitants and the only center in the region for pituitary surgery. The purely endoscopic approach has been exclusively used in transsphenoidal pituitary surgery at our department since April 2004. Before this time, from 2002 to 2004, the surgical approach was selected according to the surgeon's preference. Since the transition to

Patient and Tumor Characteristics

The surgical procedures were performed between 1996 and 2009. A total of 366 transsphenoidal surgical procedures for pituitary adenoma were performed in total, 153 were microsurgical, and 213 purely endoscopic. Of these patients, 235 completed the questionnaire (Figure 1). The remaining 131 patients are presented as a comparison regarding basic data to examine potential selection bias. The mean age was equal between both surgical techniques, but there was a significant difference in gender

Discussion

The major findings in the present study are that neither HRQoL nor working capacity is significantly different with endoscopic transsphenoidal surgery compared with microsurgery. Additional findings emerged regarding complication rates, gender differences, and influence of pituitary adenomas on HRQoL, as discussed in the next section.

Conclusions

Surgical technique does not influence pa-KPS, EQ-5D-3L, or work-related outcome in long-term follow-up. We conclude that fully endoscopic pituitary surgery is equal to conventional microsurgery concerning the risk of complications with a trend toward fewer complication rates, even for patients with bigger tumors. The surgical technique does not influence long-term HRQoL or working ability, although both are decreased among patients treated for pituitary adenomas. Females seem to have a greater

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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