Endoscopic Endonasal versus Microscopic Transsphenoidal and Open Transcranial Approaches for Giant Pituitary Adenomas

Objective: Giant (≥4 cm) pituitary macroadenomas often require surgery to decompress the optic nerves. Compared with traditional open or transsphenoidal microscopic methods, the extended endoscopic endonasal transsphenoidal approach offers the potential for aggressive resection via a minimal access corridor. We conducted a systematic review of the literature to further our understanding of the role of endoscopy in the management of these challenging lesions.

Methods: MEDLINE search of the modern literature (1995–2010) was conducted to identify surgical series for pediatric and adult pituitary adenomas > 4 cm in maximal diameter. Patient and tumor characteristics, resection, morbidity, and visual outcome were compared by approach. Chi-square and Fisher's exact tests with post-hoc Bonferroni analysis were used for statistical analyses.

Results: Sixteen studies (478 patients) were included. Compared with the open cohort, the endoscopic cohort had higher rates of gross total resection (47.2% vs. 9.6%; P < .003) and improved visual outcome (91.1% vs. 45.7%; P < .003). The microscopic transsphenoidal cohort had lower rates of total resection and worse visual outcomes than the endoscopic group. There were no instances of postoperative CSF leak reported in the endoscopic group. The transcranial group had a higher rate of perioperative mortality compared with the transsphenoidal group (P = .004).

Conclusion: In select cases, the endoscopic endonasal approach is safe and effective for the treatment of giant pituitary adenomas, with the potential for gross total resection and improved visual outcome. CSF leak, which is a major limitation of the endonasal approach, may be avoided using meticulous multi-layer closure and vascularized nasoseptal flaps.