Endoscopic pituitary surgery: a systematic review and meta-analysis

Clinical article

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Surgery on the pituitary gland is increasingly being performed through an endoscopic approach. However, there is little published data on its safety and relative advantages over traditional microscope-based approaches. Published reports are limited by small sample size and nonrandomized study design. A meta-analysis allows for a description of the impact of endoscopic surgery on short-term outcomes.


The authors performed retrospective review of data from their institution as well as a systematic review of the literature. The pooled data were analyzed for descriptive statistics on short-term outcomes.


Nine studies (821 patients) met inclusion criteria. Overall, the pooled rate of gross tumor removal was 78% (95% CI 67–89%). Hormone resolution was achieved in 81% (95% CI 71–91%) of adrenocorticotropic hormone secreting tumors, 84% (95% CI 76–92%) of growth hormone secreting tumors, and 82% (95% CI 70–94%) of prolactin secreting tumors. The pooled complication rates were 2% (95% CI 0–4%) for CSF leak and 1% (95% CI 0–2%) for permanent diabetes insipidus. There were 2 deaths reported in the literature that were both related to vascular injury, giving an overall mortality rate of 0.24%.


The results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary surgery. Future studies with long-term follow-up are required to determine tumor control.

Abbreviations used in this paper: ACTH = adrenocorticotropic hormone; GH = growth hormone; LOS = length of stay; PRL = prolactin.

Article Information

Address correspondence to: Abtin Tabaee, M.D., 10 Union Square East, Suite 4J, New York, New York 10003. email: atabaee@hotmail.com.

Please include this information when citing this paper: published online January 23, 2009; DOI: 10.3171/2007.12.17635.

© AANS, except where prohibited by US copyright law.



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    Graphic representation showing pooled rates of gross tumor removal.

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    Graphic representation showing pooled hormone resolution rates for ACTH-secreting tumors.

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    Graphic representation showing pooled hormone resolution rates for GH-secreting tumors.

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    Graphic representation showing pooled hormone resolution rates for PRL-secreting tumors.

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    Graphic representation showing pooled hormone resolution rates for all hormone-secreting tumors.

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    Graphic representation showing pooled complication rates for CSF leak.

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    Graphic representation showing pooled complication rates for both any diabetes insipidus events.

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    Graphic representation showing pooled complication rates for permanent diabetes insipidus.

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    Graphic representation showing pooled complication rates for epistaxis.

  • View in gallery

    Graphic representation showing pooled complication rates for anterior pituitary dysfunction.


  • 1

    Barker FG IIKlibanski ASwearingen B: Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 88:470947192003

  • 2

    Black PMZervas NTCandia GL: Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 20:9209241987

  • 3

    Cappabianca PCavallo LMColao Ade Divitiis E: Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:2932982002

  • 4

    Cappabianca PCavallo LMde Divitiis E: Endoscopic endonasal transsphenoidal surgery. Neurosurgery 55:9339402004

  • 5

    Casler JDDoolittle AMMair EA: Endoscopic surgery of the anterior skull base. Laryngoscope 115:16242005

  • 6

    Chandler WFSchteingart DELloyd RVMcKeever PEIbarra-Perez G: Surgical treatment of Cushing's disease. J Neurosurg 66:2042121987

  • 7

    Charpentier Gde Plunkett TJedynak PPeillon FLe Gentil PRacadot J: Surgical treatment of prolactinomas. Short- and long-term results, prognostic factors. Horm Res 22:222 2271985

  • 8

    Cho DYLiau WR: Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg Neurol 58:3713752002

  • 9

    Ciric IMikhael MStafford TLawson LGarces R: Transsphenoidal microsurgery of pituitary macroadenomas with long-term follow-up results. J Neurosurg 59:3954011983

  • 10

    Ciric IRagin ABaumgartner CPierce D: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:2252361997

  • 11

    Cushing H: Intracranial Tumors: Notes Upon a Series of Two-Thousand Verified Cases With Surgical-Mortality Percentages Pertaining Thereto Springfield, ILCharles C Thomas1932. 6979

  • 12

    Cushing H: Partial hypophysectomy for acromegaly. Ann Surg 50:100210171909

  • 13

    Cushing H: The Pituitary Body and Its Disorders Philadelphia, PAJB Lippincott Co1912. 296303

  • 14

    Davis DHLaws ER JrIlstrup DMSpeed JKCaruso MShaw EG: Results of surgical treatment for growth hormone-secreting pituitary adenomas. J Neurosurg 79:70751993

  • 15

    DerSimonian RLaird N: Meta-analysis in clinical trials. Control Clin Trials 7:1771881986

  • 16

    Dott NMBailey P: A consideration of the hypophyseal adenomata. Br J Surg 13:3143661925

  • 17

    Fahlbusch RBuchfelder MMuller OA: Transsphenoidal surgery for Cushing's disease. J R Soc Med 79:2622691986

  • 18

    Fahlbusch RBuchfelder M: Present status of neurosurgery in the treatment of prolactinomas. Neurosurg Rev 8:1952051985

  • 19

    Freda PUWardlaw SLPost KD: Long-term endocrinological follow-up evaluation in 115 patients who underwent transsphenoidal surgery for acromegaly. J Neurosurg 89:3533581998

  • 20

    Guidetti BFraioli BCantore GP: Results of surgical management of 319 pituitary adenomas. Acta Neurochir (Wien) 85:1171241987

  • 21

    Guilhaume BBertagna XThomsen MBricaire CVila-Porcile EOlivier L: Transsphenoidal pituitary surgery for the treatment of Cushing's disease: results in 64 patients and long term follow-up studies. J Clin Endocrinol Metab 66:105610641988

  • 22

    Guiot GThibant B: L'extirpation des adenomes hypophysaires par voie transsphenoidale. Neurochirurgia (Stuttg) 1:1331491959

  • 23

    Hammer GDTyrrell JBLamborn KRApplebury CBHannegan ETBell S: Transsphenoidal microsurgery for Cushing's disease: initial outcome and long-term results. J Clin Endocrinol Metab 89:634863572004

  • 24

    Hardy J: Transsphenoidal removal of pituitary adenomas. Union Med Can 91:9339451962

  • 25

    Hardy JWigser SM: Transsphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 23:6126191965

  • 26

    Horsley V: Disease of the pituitary gland. Br Med J 1:3231906

  • 27

    Jane JA JrLaws ER Jr: The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg 193:6516592001

  • 28

    Jho HD: Endoscopic transsphenoidal surgery. J Neurooncol 54:1871952001

  • 29

    Kabil MSEby JBShahinian HK: Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg 48:3483542005

  • 30

    Krieger MDCouldwell WTWeiss MH: Assessment of long-term remission of acromegaly following surgery. J Neurosurg 98:7197242003

  • 31

    Laufer IAnand VKSchwartz TH: Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 106:4004062007

  • 32

    Melmed SJackson IKleinberg DKlibanski A: Current treatment guidelines for acromegaly. J Clin Endocrinol Metab 83:264626521998

  • 33

    Onesti STPost KDComplications of transsphenoidal microsurgery. Post KDFriedman EDMcCormick P: Postoperative Complications in Intracranial Neurosurgery Chicago, ILThieme Medical Publishers1993. 6173

  • 34

    Ross DAWilson CB: Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients. J Neurosurg 68:8548671988

  • 35

    Rudnik AZawadzki TWojtacha MBazowski PGamrot JGaluszka-Ignasiak B: Endoscopic transnasal transsphenoidal treatment of pathology of the sellar region. Minim Invasive Neurosurg 48:1011072005

  • 36

    Scanlon MFPeters JRThomas JPRichards SHMorton WHHowell S: Management of selected patients with hyperprolactinaemia by partial hypophysectomy. Br Med J (Clin Res Ed) 291:154715501985

  • 37

    Schloffer H: Erfolgreiche operation eines hypophysentumors auf nasalem wege. Wien Klin Wochenschr 20:6216241907

  • 38

    Schwartz THStieg PEAnand VK: Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58:1 SupplONS44ONS512006

  • 39

    Semple PLLaws ER Jr: Complications in a contemporary series of patients who underwent transsphenoidal surgery for Cushing's disease. J Neurosurg 91:1751791999

  • 40

    Serri OSomma MComtois RRasio EBeauregard HJilwan N: Acromegaly: biochemical assessment of cure after long term follow-up of transsphenoidal selective adenomectomy. J Clin Endocrinol Metab 61:118511891985

  • 41

    Sheaves RJenkins PBlackburn PHuneidi AHAfshar FMedbak S: Outcome of transsphenoidal surgery for acromegaly using strict criteria for surgical cure. Clin Endocrinol (Oxf) 45:4074131996

  • 42

    Shen CCWang YCHua WSChang CSSun MH: Endoscopic endonasal transsphenoidal surgery for pituitary tumors. Chin Med J (Engl) 63:3013102000

  • 43

    Stroup DFBerlin JAMorton SCOlkin IWilliamson GDRennie D: Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 283:200820122000

  • 44

    Tindall GTHerring CJClark RVAdams DAWatts NB: Cushing's disease: results of transsphenoidal microsurgery with emphasis on surgical failures. J Neurosurg 72:3633691990

  • 45

    Tindall GTOyesiku NMWatts NBClark RVChristy JHAdams DA: Transsphenoidal adenomectomy for growth hormone-secreting pituitary adenomas in acromegaly: outcome analysis and determinants of failure. J Neurosurg 78:2052151993

  • 46

    White DRSonnenburg REEwend MGSenior BA: Safety of minimally invasive pituitary surgery (MIPS) compared with a traditional approach. Laryngoscope 114:194519482004




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