Prognostic indicators in pituitary adenoma surgery: a comprehensive analysis of surgical outcomes and complications

Objective

The primary aim of this study was to identify predictive factors associated with onset of de-novo clinically significant pituitary insufficiencies following endoscopic endonasal surgery (EES) for pituitary adenomas. The secondary objective explored the predictive factors of surgical success.

Methods

A retrospective analysis was conducted on 211 patients who underwent EES. Logistic regression models were employed for the primary and secondary objectives. Patients were stratified into specific groups based on surgical indications and prolactin levels for nuanced analysis.

Results

Significant predictors for de-novo pituitary insufficiencies included male sex (OR 3.3, CI95% 1.3-8.1, p=0.01), immediate postoperative insufficiencies (OR 5.6, CI95% 2.8-11.1, p<0.001), and HYPRONOS criteria (OR 5.7, CI95% 1.6-20.9, p=0.008). For surgical success, preoperative insufficiencies (OR 0.7, CI95% 0.5-0.9, p=0.008), repeat surgeries (OR 0.1, CI95% 0-0.4, p=0.001), and gonadotroph or somatotroph adenomas were significant. Age and adenoma size were not predictive in multivariate analysis. Furthermore, we observed a "dip and recover" effect of prolactin after surgery and lower prolactin levels at follow-up (< 3 ng/ml) are correlated with more anterior pituitary insufficiencies than normoprolactinemic patients (p = 0.004).

Conclusion

This study identifies key predictors for outcomes in pituitary surgery. Our research is the first to employ individualized success criteria for EES, challenging existing perceptions about the role of age and adenoma size. These findings open avenues for nuanced, individualized preoperative risk assessment and postoperative management.

Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients

BACKGROUND

The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve.

MATERIAL AND METHODS

All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records.

RESULTS

Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015).

CONCLUSION

The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.

The role of multimodal navigation in endoscopic endonasal surgery for giant pituitary adenomas

Background

Giant pituitary adenoma (GPA) (diameter >40 mm) remains challenging to treat, and the radical resection rate is low. The intraoperative multimodal navigation is sometimes used in endoscopic endonasal surgery (EES). However, the effect of this technique on GPA surgical outcomes is not clear. This study aims to explore the surgical and clinical outcomes of the navigation used in EES for GPA.

Methods

A retrospective review of 60 consecutive patients with GPA who underwent EES was performed. The total resection rate, residual volume, clinical outcomes, and complications were compared. Factors associated with tumor gross total resection (GTR) were analyzed by multinomial logistic regression analysis.

Results

There were 31 patients in the standard group in which intraoperative multimodal navigation was not used, with a mean maximum tumor diameter of 5.21±1.24 cm; meanwhile, there were 29 patients in the navigation group, in which navigation was used, with a mean maximum tumor diameter of 5.32±1.18 cm. GTR was achieved in 10 patients (32.26%) in the standard group, which was significantly lower than that in the navigation group (18/29=62.07%). The residual volume was 7.93±10.78 cm³ in the standard group which was significantly greater than that in the navigation group (2.44±1.26 cm³, P=0.046). There was no significant difference between the two groups in terms of cerebrospinal fluid (CSF) leak, new pituitary deficit, and postoperative diabetes insipidus (DI). The higher Knosp grade of tumor, lobulated configuration and lack of intraoperative multimodal navigation use were relative risk factors associated with the GTR.

Conclusions

The intraoperative multimode navigation appeared to be safe and effective when used in EES for GPA with higher GTR and lower residual tumor volume.