Trends in Endoscopic and Microscopic Approaches to Transsphenoidal Hypophysectomy in the United States, Using a Global Database Network

Introduction: Microscopic and endoscopic transsphenoidal approaches are the most common approaches to pituitary surgery. Previous studies utilizing US-based databases from 2003 to 2014 have demonstrated early predominance of microscopic approaches (MA), though rates of endoscopic approaches (EA) increased toward 2014. The current study aims to expand on previous studies and describes national trends in approaches to pituitary surgery through 2021 including geographic trends and postoperative outcomes.

Methods: Data was collected from the TriNetX, LLC database of electronic medical records from ~90 million patients from 54 healthcare organizations in the United States. Data from 2010 to 2021 was collected including demographics, geographic distribution of surgical centers, and complications within the 90-day postoperative period for patients undergoing microscopic or endoscopic transsphenoidal hypophysectomy. Complications included cerebrospinal fluid (CSF) leak, diabetes insipidus (DI), syndrome of inappropriate antidiuretic hormone (SIADH), hyponatremia, and bacterial meningitis. Additional outcomes also included postoperative stereotactic radiation, need for additional surgery, and emergency department (ED) visits or inpatient readmissions within 90 days postoperatively.

Results: Rates of EA are increasing, and rates of MA are decreasing in the United States. MA was most utilized from 2010 to 2012 (56–67% of all hypophysectomies). In 2013, the rates of EA (52%) surpassed MA (48%) and continued to increase through 2021 (81%) as the most common approach. From 2010 to 2013, EA was most pursued in the Northeast, but from 2014 to 2021 became most pursued in the South. From 2010 to 2021 EA was least pursued in the West. In terms of complications, in 2010 to 2015, EA had statistically significantly increased odds of CSF leak (OR: 3.40) and DI (OR: 2.30) compared with MA (p < 0.05), whereas in 2016 to 2020 the difference in complications among approaches was not statistically significant. In 2010 to 2015, there was no statistically significant difference in odds of SIADH, hyponatremia, or meningitis complications among approaches; however, in 2016 to 2021, EA had lower odds of SIADH (OR: 0.54) and hyponatremia (OR: 0.71), and higher odds of meningitis (OR: 1.79) compared with MA (p < 0.05). Interestingly, EA had higher odds of needing additional surgery (either EA or MA) after initial surgery, both in 2010 to 2015 (OR: 1.54) and with increasing odds in 2016 to 2021 (OR: 1.75). There was not a statistically significant difference for odds of receiving postoperative stereotactic radiation, ED visits, or inpatient readmission for EA compared with MA from 2010 to 2015 or 2016 to 2021.

Discussion: The current study investigates and expands on trends in EA and MA to pituitary tumors. Previous studies have described a predominance of the MA prior to 2014, whereas our study now demonstrates a predominance of EA with decreasing rates of MA. Previous studies have demonstrated higher complication rates after EA versus MA. However, this study's findings demonstrate decreasing rates of complications for EA, likely due to increasing surgeon experience, comfort, and advances in endoscopic technologies.

Publikationsverlauf

Artikel online veröffentlicht:
01. Februar 2023