Surgical outcome and effectiveness of regular endonasal endoscopic approach for treating giant pituitary adenoma

Abstract

Background

Giant pituitary adenomas (GPAs), defined as tumors of 4 cm or greater in maximum diameter (a volume of at least 10000 mm
3
), pose significant surgical challenges due to their size and potential for invasion into surrounding critical neurovascular structures. While the extended endonasal endoscopic approach (EEEA) has been advocated for comprehensive exposure and resection, the regular endonasal endoscopic approach (REEA) remains a less invasive alternative in selected cases. This study evaluates the surgical outcomes and effectiveness of REEA in treating GPAs, aiming to determine its feasibility as an alternative to EEEA.



Methods
A retrospective cohort study was conducted on 50 patients with GPAs who underwent REEA between January 2018 and January 2024 at a single tertiary neurosurgical center. The inclusion criteria were tumors > 4 cm with suprasellar extension manageable via REEA. A binostril four-hand technique with a rigid scope holder was used, and reconstruction involved abdominal fat graft and nasoseptal flap. Preoperative imaging, operative records, and postoperative outcomes were analyzed. Key endpoints included extent of resection (EOR), visual outcome, hormonal status, complication rates, and recurrence.


Results
Among 50 patients with pituitary adenomas, the mean age was 39.32 years (range 23–60). There were 27 males (54%) and 23 females (46%). Dominant clinical symptoms included headache (44%), visual symptoms (34%), and galactorrhea (20%). Most tumors were non-functioning adenomas (66%), with prolactinomas (20%) as the second most common. Tumor size averaged 149.82 cm³, with dumbbell-shaped (44%) and round-shaped (36%) being the most frequent morphologies. Pituitary apoplexy occurred in 18%. Suprasellar and sphenoid extensions were present in 68% and 40%, respectively. 80% of the cases had gross total resection (GTR), and 20% had subtotal resection (STR). Postoperative complications included DI (16%) and CSF leaks (10%). The average hospital stay was 4.64 days, and 84% of patients showed improvement after surgery. MRI at 3 months showed residual tumor in 20% (STR cases).


Conclusion
regular endonasal endoscopic approach remains a valuable tool in GPA management when applied to appropriately selected patients. Our study supports the growing body of evidence that a less invasive regular endonasal endoscopic approach can provide outcomes comparable to extended endonasal endoscopic approach in selected cases, with fewer complications and quicker recovery.