Surgical volume in neurosurgery [Neurosurgery Wiki]

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====== Surgical volume in neurosurgery ======


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===== Surgical Volume in Endoscopic Transsphenoidal Surgery for Pituitary Neuroendocrine Tumors (PitNETs) =====

==== Definition and Importance of Surgical Volume ====
Surgical volume refers to the **number of transsphenoidal surgeries (TSS) performed annually** at a given institution or by an individual surgeon. It is a **critical factor** in determining surgical success, complication rates, and overall patient outcomes. 

High-volume centers (HVCs) have been consistently associated with:
  * **Higher tumor resection rates**
  * **Lower complication rates**
  * **Improved long-term endocrine function**

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==== Impact of Surgical Volume on Outcomes ====
^ **Factor** ^ **High-Volume Centers (HVC)** ^ **Low-Volume Centers (LVC)** ^
| **Tumor Resection Rate** | Higher (More complete resections) | Lower (Higher residual tumor rate) |
| **Complication Rate** | Lower (<20%) | Higher (>25%) |
| **Endocrine Remission Rate** | Improved in functioning PitNETs | Lower remission rates |
| **Postoperative CSF Leak** | Reduced (<5-10%) | Increased (>10%) |
| **Hypopituitarism** | Less frequent | More common |

=== Why Does Surgical Volume Matter? ===
  * **Surgeon Experience** → More cases lead to refined techniques and better intraoperative decision-making.
  * **Institutional Expertise** → Multidisciplinary teams (neurosurgeons, endocrinologists, neuroradiologists) improve perioperative management.
  * **Technology & Equipment** → HVCs invest in neuronavigation, intraoperative MRI, and high-quality endoscopic systems.
  * **Postoperative Care** → Specialized units can better manage complications like **CSF leaks and diabetes insipidus (DI)**.

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==== Defining High-Volume Centers (HVCs) in Pituitary Surgery ====
The definition of a **high-volume center** varies, but international standards suggest:
  * **≥50 TSS per year** (some studies set a threshold of ≥100/year)
  * **Dedicated pituitary surgery team**
  * **Availability of intraoperative imaging and neuromonitoring**

'''🔹 In Spain (TESSPAIN Study, 2025):''' High-volume centers were defined as those performing **>25 TSS/year or having national expertise**, but this threshold may underestimate the benefits of very high-volume centers.

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==== Evidence Supporting Centralization of Pituitary Surgery ====
Several studies confirm **better outcomes in high-volume centers**:

  * **De Almeida et al. (2022):** Centers performing **>100 cases/year** had **higher remission rates in Cushing’s disease and GH-secreting PitNETs**.
  * **Petersen et al. (2021):** High-volume institutions had a **lower CSF leak rate** and **better visual outcomes** for macroadenomas.
  * **TESSPAIN Study (2025):** Spanish HVCs had **higher success rates (53.1% vs. 47.7%)** and lower complications.

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==== Conclusion & Recommendations ====
  * **Surgical volume is a key determinant of pituitary surgery outcomes.**  
  * **Centralization of transsphenoidal surgery in high-volume centers** improves tumor resection, endocrine remission, and reduces complications.  
  * **National guidelines should encourage referral to experienced centers** to optimize results.  

===== Retrospective multicenter observational studies ====

TESSPAIN evaluates TSS outcomes in Spanish [[center]]s to assess the influence of surgical volume and specialized [[neurosurgery team]]s on success and complication rates.

A retrospective, nationwide study of Spanish centers performing TSS between January [[2018]] and December [[2022]]. Centers were classified as [[high-volume center]]s (HV) [n=11, defined as centers with recognized expertise in Spain or those performing more than 25 TSS/year] or non-HV. Data collection included surgical success rates, complications, and pituitary adenoma resectability (R-PA). Additional analyses evaluated the impact of dedicated neurosurgical teams (DNT) within HV centers.

2815 TSS from 29 Spanish centers were included (1421 NSPA, 436 GH-secreting, 323 Cushing's disease, 127 PRL-secreting, and 25 TSH-secreting PA). The overall success rate was 50.5%, 76.8% for R-PA. HV centers had a higher overall success rate (53.1 vs. 47.7%; p=0.03). Better TSS outcomes for NSPA accounted for this difference. The overall TSS complication rate was 22.1%, which was higher for NSPA than for SPA (25.0 vs. 17.7%). The overall complication rate of TSS for PA was significantly higher in non-HV centers than in HV centers (24 vs 20.4.0; p <0.01). Centers with a DNT showed a trend to higher success rate in R-PA, while having a lower overall incidence of complications in TSS for PA than HV centers without a DNT (18.5 vs. 23.0; p=0.058), mainly reducing the rate of permanent ADH deficiency in all TSS for PA (2.7 vs. 8.4%; p<0.001).

Higher [[surgical volume]] and DNT are associated with improved TSS outcomes for PA in [[Spain]]. The results support the [[recommendation]] of concentrating [[pituitary surgery]] in a reduced number of centers of expertise in the [[country]] to improve the success rate and reduce complications, mainly postoperative ADH deficiency
((Paja M, Soto A, Hanzu FA, Guerrero-Pérez F, Cámara R, Moure D, Gálvez Á, Simó-Servat A, Villar-Taibo R, Calatayud M, Vicente A, Recio-Córdova JM, Serra G, Martín Rojas-Marcos P, Parra-Ramírez P, Araujo-Castro M, Librizzi S, Irigaray A, Ollero D, Aznar S, Muñoz F, Aulinas A, González-Fernández L, García-Centeno R, Egaña N, González-Vidal T, Menéndez E, Delgado AM, Abarca J, Sottile J, Picó AM, Novo C, Ortiz I, Tenorio C, de León R, de Pablos-Velasco P, Crespo C, Peñalver D, Díaz-Soto G, Puig-Domingo M, Biagetti B. [[Outcome]]s of [[transsphenoidal surgery]] for [[pituitary adenoma]]s in [[Spain]]: a [[retrospective]] [[multicenter study]]. Front Endocrinol (Lausanne). 2025 Feb 21;16:1529418. doi: 10.3389/fendo.2025.1529418. PMID: 40060376; PMCID: PMC11886961.))