Original ArticleEndoscopic Transsphenoidal Surgery Outcomes in 331 Nonfunctioning Pituitary Adenoma Cases After a Single Surgeon Learning Curve
Introduction
Pituitary adenomas (PAs) are the second most common brain tumors, and the prevalence is approximately 1 in 1000 in community-dwelling adults.1 PAs can be manifested as hormone secretion or mass effects. Among PAs, nonfunctioning pituitary adenomas (NFPAs) account for 14%–54%.1, 2 In NFPAs, visual symptoms is the definite surgical indication, and hypopituitarism is not an absolute surgical indication.2 The surgical removal of NFPAs does not guarantee the recovery from hormone deficiency. In addition, several reports have demonstrated that transsphenoidal surgery also carries the risk of hypopituitarism and hormonal recovery simultaneously.3, 4 However, transsphenoidal surgery for NFPAs is challenging because the tumor sizes are large, and suprasellar extension and cavernous sinus invasion are common.5, 6, 7 One critical factor for various outcomes of endoscopic surgery may be the surgeon's skills and experiences.5, 8
Microscopic transsphenoidal surgery is the traditional surgical technique. Twenty years ago, endoscopic techniques were introduced into transsphenoidal pituitary surgeries.9, 10 Compared with microscopy, the wide view of endoscopy improves the visualization of the suprasellar and lateral extension of tumors and differentiation of tumors from normal glands and surrounding tissues.11, 12 Theoretically, the wider visualization of endoscopic surgery might provide a higher gross total resection (GTR) rate and a lower complication rate. However, whether endoscopic surgery is better than microscopic surgery in terms of surgical outcomes and complications has been controversial.13, 14 For NFPAs, the GTR rate of endoscopic surgery has been reported to vary from 59% to 92%,5, 6, 7, 10, 12, 15 which appeared similar to the results for microscopic surgery (50%–83%).14, 16
Herein, we aim to assess the outcomes of endoscopic transsphenoidal surgery in terms of tumor resection, visual outcomes, and hormone outcomes after 1 surgeon's experiences over 7 years and to elucidate the predictive factors for surgical outcomes for NFPAs.
Section snippets
Study Population
The study was approved by the Institutional Review Board of Seoul National University Hospital (number 1503-040-654). We reviewed 331 patients (155 men and 176 women) with clinical NFPAs who underwent transsphenoidal surgery because of visual symptoms by a single surgeon in Seoul National University Hospital from March 2010 to May 2016. We excluded pituitary apoplexy cases. All patients were followed-up at a postoperative visit 3 months after surgery and were assessed by an endocrinologist and
Results
Baseline characteristics of study subjects are shown in Table 1. The median age was 53.0 years, and median body mass index was 24.9 kg/m2. Of 331 patients, 97 patients had a history of previous surgery and 15 patients received gamma-knife surgery or radiation previously. Only 2 cases were microadenomas, and 46 cases (13.9%) were giant adenomas >4 cm. Cavernous sinus invasion (Knosp grade ≥3) was identified in 144 cases (43.5%). Preoperative visual assessment data were available in 322 patients,
Discussion
In this study, the success rate of endoscopic transsphenoidal surgery for NFPAs by a single surgeon was 74.9% and was affected by cavernous sinus invasion, tumor size, previous history of surgery, and surgical experiences. Overall, hormonal outcomes were not improved by endoscopic transsphenoidal surgery. Visual outcomes were improved in 73.4% of all patients, and favorable outcomes were expected in those with smaller adenomas, no history of previous surgery or radiation, and in whom the
Acknowledgments
We thank all colleagues who contributed to the study.
References (28)
- et al.
Predictors of short-term outcomes following endoscopic pituitary surgery
Clin Neurol Neurosurg
(2009) - et al.
A benchmark for preservation of normal pituitary function after endoscopic transsphenoidal surgery for pituitary macroadenomas
World Neurosurg
(2016) Diagnosis and treatment of pituitary adenomas: a review
JAMA
(2017)- et al.
Pituitary incidentaloma: an endocrine society clinical practice guideline
J Clin Endocrinol Metab
(2011) - et al.
Pituitary hormonal loss and recovery after transsphenoidal adenoma removal
Neurosurgery
(2008) - et al.
Improved versus worsened endocrine function after transsphenoidal surgery for nonfunctional pituitary adenomas: rate, time course, and radiological analysis
J Neurosurg
(2016) - et al.
Endoscopic endonasal transsphenoidal surgery of 1,166 pituitary adenomas
Surg Endosc
(2015) - et al.
Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series
Neurosurgery
(2008) - et al.
Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center
Pituitary
(2010) - et al.
Endoscopic endonasal pituitary adenomas surgery: the surgical experience of 178 consecutive patients and learning curve of two neurosurgeons
BMC Neurol
(2016)
Endoscopic transsphenoidal surgery
J Neurooncol
Endoscopic endonasal transsphenoidal surgery
Neurosurgery
Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors
J Neurosurg
The endoscopic versus the traditional approach in pituitary surgery
Neuroendocrinology
Cited by (62)
The Learning Curve for Endoscopic Endonasal Transsphenoidal Pituitary Surgery: Evaluating Endocrine Outcomes
2024, Journal of Clinical NeuroscienceLearning Curve for Endoscopic Transsphenoidal Surgery: A Systematic Review and Meta-Analysis
2024, World NeurosurgerySerum and hair steroid profiles in patients with nonfunctioning pituitary adenoma undergoing surgery: A prospective observational study
2023, Journal of Steroid Biochemistry and Molecular Biology
Conflict of interest statement: This study was supported by a grant (HI16C-1111-020016; to Y. H. K.) from the Korea Health Industry Development Institute.