Economic Burden and Cost-effectiveness of Endoscopic versus Microscopic Transsphenoidal Surgery for Pituitary Adenomas

Objective: Transsphenoidal surgery is the gold standard for treating almost all pituitary tumors and can be performed using a microscopic or endoscopic approach. While the microscopic approach has remained the mainstay for transsphenoidal surgeries for pituitary adenomas, the endoscopic approach has become popular due to improved visualization of the surgical field. We analyzed the economic burden and cost-effectiveness of the two approaches.

Methods: A retrospective review of patients with pituitary adenomas (2007–2013) who were surgically treated at a single institution and corresponding in-patient hospital charges was done.

Results: Of 192 pituitary adenomas patients (median age = 47.2; females = 54.2%), 90 (46.8%) patients underwent endoscopic approaches while 102 (53.2%) underwent microscopic approaches. All endoscopic approaches were done with OHNS assistance while microscopic approaches were done by neurosurgeons without OHNS assistance. When assessing temporal trends over the course of the study, there was a gradual increase in the number of cases in the endoscopic group, with 4.43 more cases on average every year (R-square = 0.88, p = 0.002), while there was a gradual decline in the number of microscopic cases by 1.2 cases per year (R-square = 0.35, p = 0.032). Tumor characteristics were similar between endoscopic and microscopic approaches. The endoscopic cohort had lower total inpatient hospital costs compared with the microscopic cohort ($26,805 vs. $37,371; p = 0.001). When analyzing by cost category, endoscopic patients had lower costs associated with room/board ($7,328.48 vs. $9,866.27, p = 0.01) and operative costs ($7,035.27 vs. $9,129.61, p = 0.02) as compared with the microscopic group, while cost associated with laboratories, imaging, in-hospital pharmacy, pathology or any inpatient treatments were similar in both groups. Postoperatively, the endoscopic cohort had shorter hospital stays, while microscopic patients had greater hospital length of stay (2.1 vs. 2.8 days; p = 0.02). Postoperative complications were similar between the two surgical groups. Progression-free survival was significantly longer in endoscopic patients when compared with microscopic patients (4.6 vs. 4.1 years, p = 0.04). QALY scores were 3.7 and 3.21 for endoscopic and microscopic groups, respectively (p = 0.026). The incremental cost per QALY was $21,563 lower for the endoscopic approach.

Conclusion: While the microscopic approach to transsphenoidal pituitary tumors has been the dominant approach, the endoscopic approach has become more popular in recent years. In this single institution study, the endoscopic approach was associated with lower hospital charges despite involving dual specialty co-surgeries, shorter stay in the hospital, and better QALY scores and progression-free survival. Multi-institutional validation of these findings could offer valuable information to centers considering transitioning to endoscopic approaches and could be of value in justifying multidisciplinary co-surgeries to cost-conscious insurance companies.