Elsevier

World Neurosurgery

Volume 101, May 2017, Pages 236-246
World Neurosurgery

Original Article
Endoscopic Versus Microscopic Transsphenoidal Surgery in the Treatment of Pituitary Adenoma: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.wneu.2017.01.022Get rights and content

Background

Inconsistent findings have been reported regarding the efficacy and safety of endoscopic and microscopic transsphenoidal surgery for pituitary adenoma. This study aimed to assess the benefits and shortcomings of these surgical methods in patients with pituitary adenoma.

Methods

The electronic databases PubMed, Embase, and the Cochrane Library were systematically searched, as well as proceedings of major meetings. Eligible studies with a retrospective or prospective design that evaluated endoscopic versus microscopic methods in patients with pituitary adenoma were included. Primary outcomes included gross tumor removal, cerebrospinal fluid leak, diabetes insipidus, and other complications.

Results

Overall, 23 studies (4 prospective and 19 retrospective) assessing 2272 patients with pituitary adenoma were included in the final analysis. Endoscopic transsphenoidal surgery was associated with a higher incidence of gross tumor removal (odds ratio, 1.52; 95% confidence interval, 1.11–2.08; P = 0.009) than those with microscopic transsphenoidal surgery. In addition, endoscopic transsphenoidal surgery had no significant effect on the risk of cerebrospinal fluid leak, compared with microscopic transsphenoidal surgery. Furthermore, endoscopic transsphenoidal surgery was associated with a 22% reduction in risk of diabetes insipidus compared with microscopic transsphenoidal surgery, but the difference was not statistically significant. Endoscopic transsphenoidal surgery significantly reduced the risk of septal perforation (odds ratio, 0.29; 95% confidence interval, 0.11–0.78; P = 0.014) and was not associated with the risk of meningitis, epistaxis, hematoma, hypopituitarism, hypothyroidism, hypocortisolism, total mortality, and recurrence.

Conclusions

Endoscopic transsphenoidal surgery is associated with higher gross tumor removal and lower incidence of septal perforation in patients with pituitary adenoma. Future large-scale prospective randomized controlled trials are needed to verify these findings.

Introduction

Pituitary adenomas account for approximately 10% of all primary intracranial tumors.1 They are classified based on hormonal activity: nonsecreting, prolactinoma, and adrenocorticotropic hormone, growth hormone, and thyroid-stimulating hormone producing, respectively.2 Because medication usually yields unacceptable side effects in patients with pituitary adenoma, transsphenoidal surgery is a well-established choice in the treatment of this tumor and has continuously improved in the past decade.3 Microsurgery via a transsphenoidal approach is widely used for pituitary surgery and has become the gold standard, merging microscopy and intraoperative fluoroscopy.4, 5 Over the past decade, endoscopic transsphenoidal surgery has been increasingly used to remove pituitary tumors and other lesions of the sella.6, 7, 8 However, how these 2 surgical methods compare remains controversial.

Ammirati et al.9 performed a meta-analysis to evaluate the short-term effects of endoscopic and microscopic pituitary adenoma surgeries and found that endoscopic removal of pituitary adenomas does not seem to confer any advantages over the microscopic technique; in addition, vascular complications were significantly more common in the endoscopy group compared with the microscopy group. However, Gao et al.10 indicated that endoscopic surgery is associated with higher gross tumor removal (GTR), with a lower risk of septal perforation, yielding inconsistent results from the 2 interventions. Recently, several studies investigating endoscopic versus microscopic surgeries have been reported. To evaluate the potential benefits and complications of the 2 transsphenoidal surgery types, a comprehensive systematic review and meta-analysis of pooled data were performed, including the latest efficacy and safety findings of endoscopic versus microscopic methods in the treatment of pituitary adenomas.

Section snippets

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of Weifang People's Hospital research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Data Sources and Search Strategy

This review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement issued in 2009 (Checklist

Results

The study selection process is presented in Figure 1. A total of 410 articles were identified in the initial electronic search; of these, 364 were excluded after removal of duplicates and irrelevant studies during an initial review based on titles and abstracts. Then, full texts were retrieved for the remaining 46 studies. After detailed evaluation, 23 studies met the inclusion criteria and were selected for final analysis.20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37,

Discussion

The current standard interventions for pituitary adenomas are transsphenoidal surgery by endoscopic or microscopic approaches. However, the efficacy and safety of the 2 surgical procedures remain controversial. Previous meta-analyses do not provide certain evidence for intervention effects. An increasing number of trials have evaluated endoscopic and microscopic surgeries for efficacy and safety in the treatment of pituitary adenomas and acquired varying data, and doctors have few

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    Conflict of interest statement: This study was supported by the Shandong Medical Science and Technology Development Plan (no. 2014WS0265).

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