Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study

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  • 1 Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona;
  • | 2 Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, California;
  • | 3 University of Pittsburgh, Pittsburgh, Pennsylvania;
  • | 4 Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri;
  • | 5 Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
  • | 6 Department of Neurological Surgery, The Ohio State University, Columbus, Ohio; and
  • | 7 Department of Neurological Surgery, University of Washington, Seattle, Washington
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OBJECTIVE

Many surgeons have adopted fully endoscopic over microscopic transsphenoidal surgery for nonfunctioning pituitary tumors, although no high-quality evidence demonstrates superior patient outcomes with endoscopic surgery. The goal of this analysis was to compare these techniques in a prospective multicenter controlled study.

METHODS

Extent of tumor resection was compared after endoscopic or microscopic transsphenoidal surgery in adults with nonfunctioning adenomas. The primary end point was gross-total tumor resection determined by postoperative MRI. Secondary end points included volumetric extent of tumor resection, pituitary hormone outcomes, and standard quality measures.

RESULTS

Seven pituitary centers and 15 surgeons participated in the study. Of the 530 patients screened, 260 were enrolled (82 who underwent microscopic procedures, 177 who underwent endoscopic procedures, and 1 who cancelled surgery) between February 2015 and June 2017. Surgeons who used the microscopic technique were more experienced than the surgeons who used the endoscopic technique in terms of years in practice and number of transsphenoidal surgeries performed (p < 0.001). Gross-total resection was achieved in 80.0% (60/75) of microscopic surgery patients and 83.7% (139/166) of endoscopic surgery patients (p = 0.47, OR 0.8, 95% CI 0.4–1.6). Volumetric extent of resection, length of stay, surgery-related deaths, and unplanned readmission rates were similar between groups (p > 0.2). New hormone deficiency was present at 6 months in 28.4% (19/67) of the microscopic surgery patients and 9.7% (14/145) of the endoscopic surgery patients (p < 0.001, OR 3.7, 95% CI 1.7–7.7). Microscopic surgery cases were significantly shorter in duration than endoscopic surgery cases (p < 0.001).

CONCLUSIONS

Experienced surgeons who performed microscopic surgery and less experienced surgeons who performed endoscopic surgery achieved similar extents of tumor resection and quality outcomes in patients with nonfunctioning pituitary adenomas. The endoscopic technique may be associated with lower rates of postoperative pituitary gland dysfunction. This study generally supports the transition to endoscopic pituitary surgery when the procedure is performed by proficient surgeons, although both techniques yield overall acceptable surgical outcomes.

CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: prospective cohort trial; evidence: class III.

Clinical trial registration no.: NCT02357498 (clinicaltrials.gov)

ABBREVIATIONS

GTR = gross-total resection; STR = subtotal resection; TRANSSPHER Study = Transsphenoidal Extent of Resection Study.

Illustration from Duan et al. (pp 1174–1181).

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Contributor Notes

Correspondence Andrew S. Little: c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. neuropub@barrowneuro.org.

INCLUDE WHEN CITING Published online March 22, 2019; DOI: 10.3171/2018.11.JNS181238.

Disclosures Dr. Little is a stockholder in Kogent Surgical, LLC, and has stock options in SPIWay, LLC. Dr. Kelly receives royalties from Mizuho America Inc. Dr. Chicoine has received unrestricted grant funding from IMRIS Inc. Dr. Barkhoudarian has received consulting fees from Vascular Technology Inc. Dr. Gardner is a stockholder in SPIWay, LLC. Dr. Prevedello is a consultant for Stryker Corp., Medtronic, plc, and Codman Neuro, and he receives royalties from KLS Martin, LP.

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