Comparative Cost Analysis of Endoscopic versus Microscopic Transsphenoidal Surgery for Pituitary Adenomas

Introduction: Pituitary tumors are the third most common primary intracranial tumor and the pituitary tumor surgeries can cost up to $100 million annually. The transsphenoidal surgical approach presents a common technique to resect pituitary adenomas. Two methods that are commonly employed for this approach include the endonasal microscopic or endoscopic approach. Both the microscopic and endoscopic approaches are used throughout the world, and which technique is better or more cost effective continues to be debated. We present a comparative analysis of the surgical efficacy and inpatient costs between the microscopic and endoscopic approaches, evaluating neurological outcome, extent of resection and inpatient costs.

Method: Retrospective analysis of a cohort of 34 patients with pituitary adenomas who underwent a endonasal transsphenoidal surgery with an operating microscope, the microscopic group, were case-control matched with 34 patients with pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery, the endoscopic group between August 2005 and January 2014. All patients were operated on by a single surgeon at a single institution. Inpatient costs, volumetric extent of resection (EOR), quality adjusted life years (QALY), and neurological outcomes were compared. Linear Regression analysis was used to determine predictors of increased inpatient total costs.

Results: The baseline characteristics of the two cohorts were well matched. Total inpatient expense per patient was $22,295 in the microscopic group and $20,550 in the endoscopic group (p = 0.206). Operating room costs were $5,442 in the microscopic group and $5,650 in the endoscopic group (p = 0.626). QALY score for the microscopic group was 4.05 and 3.62 for the endoscopic group (p = 0.301). Extent of resection was similar in the microscopic (84.8%) and endoscopic groups (85.5%) (p = 0.882). Postoperative outcomes and complications were similar in both cohorts. Length of hospital stay (LOS) was 3.38 days for the microscopic group and 2.53 days for the endoscopic group (p = 0.115). An exploratory univariate analysis identified covariates of interest that may present primary drivers of total inpatient costs, which included length of hospital stay, operating room time, and functional adenomas (Table 1). Multivariate modeling evaluating these covariates of interest (LOS, operative time, and functional adenomas) suggested that (LOS) (p < 0.001, Fig. 1) and operative time (p = 0.008, Fig. 2) were predictive of total inpatient costs.

Conclusion: The total inpatient costs for transsphenoidal surgery for pituitary adenomas were found to be similar between the microscopic and endoscopic approach. We found that predictors that may influence total inpatient costs included length of stay and operative time. This study suggests that cost effectiveness for endonasal transsphenoidal pituitary adenoma surgery may depend on efficiency in the operating room as well as with postoperative care.

Table 1

Fig. 1 Linear Regression demonstrating a significant association between length of hospital stay and total inpatient cost (p < 0.001).

Fig. 2 Linear Regression demonstrating a significant association between operative costs and total inpatient cost (p = 0.015).