The endoscopic transsphenoidal approach (ETSA) has become the standard surgical method for PitNETs, offering advantages over the traditional microscopic approach, including improved visualization, better tumor resection rates, and lower complication rates.
| Feature | Endoscopic Approach | Microscopic Approach |
|---|---|---|
| Visualization | Wide-angle, panoramic | Narrower field |
| Depth Perception | 3D with angled endoscopes | 2D view |
| Tumor Resection | Better for suprasellar & cavernous sinus extension | Limited |
| Invasiveness | Less nasal trauma | More retraction required |
| Complication Rate | Lower risk of CSF leaks, nasal complications | Higher risk of damage to nasal structures |
| Complication | Incidence (%) | Notes |
|---|---|---|
| CSF leak | 5-10% | Higher in large, invasive tumors |
| Diabetes insipidus (transient) | 20-30% | Most cases resolve spontaneously |
| Permanent DI | ~2-5% | Requires desmopressin |
| Hypopituitarism | 5-25% | May require hormone replacement |
| Carotid artery injury | <1% | Life-threatening, rare |
The endoscopic transsphenoidal approach has revolutionized the surgical treatment of PitNETs, offering better visualization, higher resection rates, and lower complication risks compared to traditional microscopic surgery. While the approach has limitations in highly invasive tumors, technological advancements continue to improve outcomes.
TESSPAIN evaluates TSS outcomes in Spanish centers to assess the influence of surgical volume and specialized neurosurgical teams 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 (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 1)