Introduction
Literature search
Data extraction
Quality assessment
Quality category | Questions | Response | ||
---|---|---|---|---|
Yes | No | Unclear | ||
Demographic details | Is the age and gender for each surgical group defined? | |||
Is the role of neurosurgery and ENT clearly defined? | ||||
Are the number of patients examined clearly defined? | ||||
Is it defined if these cases are sequential or part of a larger surgical series? | ||||
Preoperative variables | Is the number of functional and non-functional adenomas defined? | |||
Are the different types of functional adenomas defined? | ||||
Is the endocrine function of non-functional adenomas clearly defined? | ||||
Is the method of quantitative visual assessment defined for all patients? | ||||
Is tumour size and tumour invasion clearly defined? | ||||
Is the method of assessing endocrine function clearly defined? | ||||
Postoperative variables | Is the rate of gross total resection clearly defined for all groups? | |||
Is the timing interval for when each outcome is examined clearly defined? | ||||
Is the method of determining visual outcome clearly defined? | ||||
Is the rate of endocrine cure clearly defined for all surgical groups? | ||||
Are the hormonal outcomes for non-functional adenomas clearly defined? | ||||
Is the method of how endocrine cure is determined clearly defined? | ||||
Is the further treatments required during follow-up defined? | ||||
Complications | Is the rate of postoperative CSF leak clearly defined for all groups? | |||
Is the rate of permanent diabetes insipidus clearly defined for all groups? | ||||
Learning curve | Is the method for how each surgical group is created clearly defined? | |||
Are all outcomes examined to see how they are affected by surgical experience? | ||||
Is the statistical method for how the learning curve is assessed clearly defined? |
Quality category | Poor | Moderate | Good |
---|---|---|---|
Demographic details | <4 criteria | 3 of 4 criteria | 4 of 4 criteria |
Preoperative variables | <5 criteria | 5 of 6 criteria | 6 of 6 criteria |
Postoperative variables | <6 criteria | 6 of 7 criteria | 7 of 7 criteria |
Complications | <2 criteria | 2 of 2 criteria | |
Learning curve | <3 criteria | 3 of 3 criteria |
Results
Study selection
Study characteristics
Demographic findings
Patient demographics
Mean age | Gender | Adenoma type | Endocrinopathy of FPA | Endocrinopathy of NFPA | Vision | Tumour size | Tumour invasion | |
---|---|---|---|---|---|---|---|---|
Kenan et al. | 41.3 group I 48.1 group II | Not reported | 19/78 (24%) NFPA 59/78 (76%) FPA | 28/59 (47%) prolactinoma 21/59 (35%) somatotropinoma 4/59 (7%) corticotropinoma 2/59 (3%) thyrotropinoma 4/59 (7%) mixed | Not reported | Not reported | Not reported | Not reported |
Leach et al. | 51* | 70/125* (56%) M 55/125* (44%) F | 73/114 (64%) NFPA 41/114 (36%) FPA | 22/41 (53%) somatotropinoma 10/41 (24%) corticotropinoma 9/41 (22%) prolactinoma 6/114 (5%) PA | Not reported | 61/125 (49%) VF in at least 1 eye | Macroadenoma 106/125* (85%) | Not reported |
Bokhari et al. | 56.7 | 35/79 (44%) M 44/79 (56%) F | 39/79 (49%) NFPA 40/79 (51%) FPA | 19/40 (48%) somatotropinoma 16/40 (40%) prolactinoma 4/40 (10%) corticotropinoma 1/40 (2%) thryrotropinoma | Not reported. 22/79 (28%) hypopituitarism for all patients | 22/79 (28%) VF abnormality 11/79 (14%) VA abnormality | 72/79 (91%) macroadenomas 7/79 (9%) microadenomas | Not reported |
Chi et al. | 52.45 group I 49.25 group II | 45/80 (56%) M 35/80 (44%) F | 34/80 (43%) NFPA 46/80 (57%) FPA | 26/46 (57%) prolactinoma 9/46 (20%) somatotropinoma 3/46 (6%) corticotropinoma 3/46 (6%) thyrotropinoma 5/46 (11%) mixed | Not reported | 57/80 (72%) VF abnormality | 64/80 (80%) macroadenoma 16/80 (20%) microadenoma | Not reported |
Shou et al. | Not reported | 78/178 (44%) M 100/178 (56%) F | 92/178 (52%) NFPA 86/178 (48%) FPA | 43/86 (50%) somatotropinoma 32/86 (37%) prolactinoma 4/86 (5%) corticotropinoma 7/86 (8%) mixed | Not reported | 65/178 (^) VF abnormality 6/178 (^) CNO | Not reported | Hardy I 17/178(9.5%) Hardy II 58/178 (32.6%) Hardy III 72/178 (40.4%) Hardy IV 31/178 (17.4%) |
Qureshi et al. | 52.2 group I 52.7 group II | 43/78 (57%) M 35/78 (43%) F | Not reported | Not reported | Not reported | 57/78 (73%) VD | 75/78 (96%) macroadenoma 3/78 (4%) microadenoma MTV 6.51cm3 group I 15.73cm3 group II | Not reported |
Kim et al. | 53 | 155/331 (46.8%) M 176/331 (53.2%) F | 331/331 (100%) NFPA | Only reported NFPA | 227/331 (68.6%) Hypopituitarism 127/331(^) GH deficiency 92/331 (^) ACTH deficiency 62/331 (^) TSH deficiency 197/331 (^) gonadotrophin deficiency 33/331 (10%) panhypopituitarism | 167/322 (51.9%) VIS 1 107/322 (33.2%) VIS 2 25/322 (7.8%) VIS 3 23/322 (7.1%) VIS 4 | 283/331 (85.5%) macroadenoma 46/331 (13.9%) giant macroadenoma | 45/331 (13.6%) Knosp 0 55/331 (16.6%) Knosp 1 87/331 (26.3%) Knosp 2 103/331 (31.1%) Knosp 3 41/331 (12.4%) Knosp 4 |
Younus et al. | 52 | 305/600 (51%) M 295/600 (49%) F | 441/600 (73%) NFPA 159/600 (27%) FPA | 67/159 (42%) prolactinoma 53/159 (33%) somatotropinoma 38/159 (25%) corticotropinoma | Not reported | 299/600 (^) VDef 13/600 (^) CNO | MMD: 23.3mm, 24.5mm, 22.5mm and 23.3mm got each quartile | Cavernous sinus invasion#: 28/150, 37/150, 44/150, 41/150. |
Boetto et al. | 59 | 30/53 (56%) M 23/53 (44%) F | 53/53 NFPA | Only reported NFPA | Endocrine symptoms not defined: 5/30 (17%) | 5/23 (22%) | 28/53 (52%) VDef | MMD 27.5mm MTV 7.37cm3 | 5/53 (9.4%) Knosp 0 12/53 (23%) Knosp 1 16/53 (30%) Knosp 2 8/53 (15%) Knosp 3a 3/53 (5.7%) Knosp 3b 9/53 (17%) Knosp 4 |
Huang et al. | 52 | 137/273 (50.2%) M 136/273 (49.8%) F | 182/273 (66%) NFPA 91/273 (34%) FPA | 50/91 (56%) somatotropinoma 38/91 (42%) prolactinoma 2/91 (2%) corticotropinoma 1/91 (1%) thyrotropinoma | Not reported | 124/273 (45%) VDef | 6/273 (2%) microadenoma 231/273 (85%) macroadenoma 36/273 (13%) giant macroadenoma | 17/273 (6.2%) Knosp 0 65/273 (24%) Knosp 1 89/273 (33%) Knosp 2 73/273 (27%) Knosp 3 29/273 (9.8%) Knosp 4 |
Outcome findings
Rates of resection | Average operating time (min) | Postoperative CSF leak rate | Visual outcomes | Endocrine outcome/cure FPA | Endocrine outcome NFPA | Rate of DI | Further treatment | |
---|---|---|---|---|---|---|---|---|
Kenan et al. | NFPA: 6/10 (55%)| 7/9 (77%) Macroprolactinoma: 6/11 (55%) | 9/12 (75%) Macrosomatotropinoma: 4/8 (50%) | 6/9 (66%) All macroadenomas*: 16/29 (55%) | 22/30 (73%) | Macroadenoma* 175 | 130 Microadenoma* 130| 95 | 1/40 (2.5%) | 1/38 (2.6%) | Not reported | Microadenomas were excluded Macroprolactinoma: 6/11 (55%) | 8/12 (66%) Macrosomatotropinoma: 4/8 (50%) | 6/9 (66%) | New anterior pituitary insufficiency: 2/40 (5%) | 0/38 (0%) | Permanent DI: 0/40 (0%) | 1/38 (2.6%) | Not reported |
Leach et al. | Large tumour residual: 2/53 (4%) | 4/72 (6%) | NFPA* 120 | 91 FPA 137 | 145 | 4/125 (3.2%) | VF improvement*: 16/20 (80%) | 38/41 (93%) VF unchanged/worse: 4/20 (20%) | 3/41 (7%) | Somatotropinoma: 12/15 (80%) | 6/7 (86%) Corticotropinoma: 2/4 (50%) | 5/6 (83%) | New anterior hypopituitarism: 8/53 (17%) | 18/72 (25%) | New permanent DI 2/53 (4%) | 4/72 (6%) | Postoperative radiotherapy 37/125 (30%) |
Bokhari et al. | Overall 50/79 (63%) GTR NFPA 19/39 (49%) GTR FPA 31/40 (78%) GTR: 56% | 58% | 77% | Not reported | Total 2/79 (3%) | VF 89% | 75% | 100% | Overall cure*: 15% | 41% | 78% Somatotropinoma 11/19 (58%) Prolactinoma 7/16 (44%) Corticotropinoma 2/4 (50%) Thyrotropinoma 1/1 (100%) | All patients eupituitary preop remained postop | Permanent DI 2/79 (2.5%) | 34 (43%) required further treatment: 21/34 (62%) pharmacotherapy, 11/34 (32%) radiotherapy, 2/34 (6%) further surgery |
Chi et al. | Overall GTR*: 21/40 (52.5%) | 30/40 (75%) | Not reported | Overall: 1/40 (2.5%) | 3/40 (7.5%) | VF improvement: 21/28 (75%) | 26/29 (89.7%) | Overall*: 7/19 (36.8%) | 18/27 (66.7%) | All patients eupituitary preop remained postop | Overall: 3/80 (3.25%) | Not reported |
Shou et al. | Overall* 129/178 (72.5%) NFPA 66/92 (72%) FPA 63/86 (73%) | Not reported | 1/178 (0.5%) | Not reported | Overall 38/86 (44%) Cure for invasive FPA: 2/19 (11%) | 10/35 (29%) | Not reported | Not reported | NFPA 5/92 (5.4%) salvage RTx 12/86 (14%) salvage RTx |
Qureshi et al. | GTR: 8/9 (89%) | 64/68 (94%) | *206 | 164 | 1/9 (11%) | 0/68 (0%) | VF: 8/8 (100%) | 47/49 (95.9%) | Not reported | Panhypopituitarism: 1/9 (11%) | 9/68 (13%) | Permanent DI: 1/9 (11%) | 4/68 (5.8%) | Not reported |
Kim et al. | GTR* 63% | 80.1% | Not reported | 8/331 (2.4%) | Overall: 73.4% improvement, 2.7% worsened Predictor for VR OR 2.15 (1.25–3.70) | Only reported NFPA | All patients: normal to normal 18.7%, normalised 6.3%, improved 15.4%, persistent 27.2%, worsened 32.9% Predictor for ER OR 1.23 (0.65–2.32) | 10/331 (3%) | Not reported |
Younus et al. | GTR overall*: 83/150 (55%) | 102/150 (68%) | 105/150 (70%) | 118/150 (79%) GTR NFPA*: 61/109 (56%) | 85/113 (75%) | 72/110 (65%) | 97/109 (89%) | Not reported | 5/150 (3%) | 2/150 (1.3%) | 1/150 (0.7%) | 1/150 (0.7%) | Normal vision postop: 139/150 (93%) | 132/150 (88%) | 125/150 (83%) | 133/150 (89%) Worsened vision postop: 0/150 (0%) | 2/150 (1%) | 5/150 (3%) | 0/150 (0%) | EC all FPA*: 68% | 78%| 88% | 90% EC prolactinoma: 74% | 80% | 93% | 89% EC somatotropinoma: 67% | 73% | 87% | 92% EC cortictropinoma: 57% | 80% | 80% | 91% | Eupituitary postop: 81% | 84% | 87% | 90% | Not reported | Not reported |
Boetto et al. | GTR: 18/30 (60%) | 19/23 (83%) | *127 | 113 | 0 (0%) | 2/23 (8.6%) | Complete recovery: 8/30 (27%) | 10/23 (43%) Partial recovery: 9/30 (30%) | 3/23 (13%) Stabilisation: 13/30 (43%) | 10/23 (43%) Worsening: 0 (0%) | 0 (0%) | Only NFPA reported | Worsened hypopituitarism: 4/30 (13%) | 1/23 (4.3%) | Permanent DI: 1/30 (3.3%) | 1/23 (4.3%) | Not reported |
Huang et al. | GTR overall*: 47/91 (51.6%) | 59/91 (64.8%) | 63/91 (69.2%) | *169 | 152| 147 | 11/91 (12.1%) | 6/91 (6.6%) | 5/91 (5.5%) | Not reported | EC overall: 12/32 (37.5%) | 16/27 (59.3%) | 18/32 (56.3%) EC prolactinoma: 5/15 (33.3%) | 5/7 (71.4%) | 7/16 (43.8%) EC somatotropinoma: 6/15 (40%) | 11/12 (55%) | 10/15 (66.7%) | Not reported | Permanent DI 4/273 (1.5%) | Not reported. |
Study quality
Paper | Demographic details | Preoperative variables | Postoperative variables | Complications | Learning curve | Overall quality |
---|---|---|---|---|---|---|
Kenan et al. | Moderate | Low | Low | High | High | Low |
Leach et al. | High | Low | Low | Low | Low | Low |
Bokhari et al | High | Low | Low | High | High | Low |
Chi et al. | High | Low | Moderate | High | High | Moderate |
Shou et al. | Moderate | Low | Low | Low | High | Low |
Qureshi et al. | High | Low | Low | High | High | Low |
Kim et al. | High | High | Moderate | High | High | Moderate |
Younus et al. | High | Low | Low | Poor | High | Low |
Boetto et al. | High | Low | Moderate | High | High | Moderate |
Huang et al. | High | Low | Low | High | High | Low |
Discussion
Rates of gross total resection
CSF leak rate
Visual outcome
Endocrine outcome
Learning curve
Preoperative | Intraoperative | Postoperative | |||
---|---|---|---|---|---|
Previous radiotherapy | ⊗ Yes ⊗ No | CSF leak | Graded as per Esposito et al 2007 | CSF leak (early = < 7 days, late = >7 days) | ⊗ Early ⊗ Late |
Endocrine | Condition of each axis as determined by endocrinologist (Hypo/normo/hyper) | Major vascular injury | Defined as arterial injury requiring harvesting of muscle patch for management | DI (temporary = no longer requiring DDAVP on first postoperative review) | ⊗ No ⊗ Temporary ⊗ New and permanent ⊗ Preexisting |
Radiological | Maximal tumour diameter in any dimension | Reconstruction (graded approach to repair, each number indicates escalating level of reconstruction) | 1. Onlay repair. local mucosa and/or dural substitute 2. Multilayer repair Inlay repair ⊗ Fat ⊗ Dural substitute ⊗ Fascia ⊗ Cartilage/bone Onlay ⊗ Fascia ⊗ Dural substitute ⊗ Fat Vascularised ⊗ Nasoseptal ⊗ Inferior turbinate ⊗ Lateral turbinate 3. Packing ⊗ Gelfoam ⊗ Nasopore ⊗ BIPP 4. Sealant ⊗ Yes ⊗ No 5. Preop lumbar drain ⊗ Yes ⊗ No | Surgical goal achieved | ⊗ Yes ⊗ No |
Knosp grade | |||||
Previous surgery | ⊗ Yes ⊗ No | Visual outcome at 6–12 weeks | Visual acuity | ||
Number of previous surgeries | If possible link copy of OCTs/visual fields. If not, describe change in VF defect | ||||
⊗ Worsened ⊗ Stable ⊗ Improved | |||||
Visual status (quantitative measure) | ⊗ Visual acuity ⊗ If possible link copy of OCTs/visual fields. If not, describe VF defect | Endocrine outcome (new deficit = new insufficiency that requires treatment, recovery of deficit = preop deficit that no longer requires supplementation, endocirne cure = complete endocrine remission, partial endocrine cure = improved medical control but still requiring treatment) | Condition of each axis as determined by endocrinologist (Hypo/normo/hyper) | ||
⊗ No change ⊗ New deficit ⊗ Recovery of deficit ⊗ Endocrine cure ⊗ Partial endocrine cure | |||||
Surgical goal | ⊗ Optic decompression ⊗ Hormonal control ⊗ Gross total resection | Extent of resection (GTR = no residual tumour on first postoperative imaging) | ⊗ GTR ⊗ Not GTR | ||
Condition at last known follow-up | ⊗ No recurrence ⊗ Residual under surveillance ⊗ Recurrence under surveillance ⊗ Progression of residual/recurrence requiring further treatment ⊗ Recurrence of endocrinopathy requiring further treatment |