Safety and efficacy of endoscopic vs. microscopic approaches in pituitary adenoma surgery: A systematic review and meta-analysis.

Pituitary adenomas (PAs) represent a prevalent category of intracranial tumors, frequently resulting in endocrine dysfunction and neurological impairments. Transsphenoidal surgery (TSS) serves as the primary treatment modality, with the endoscopic transsphenoidal approach (ETSA) and microscopic transsphenoidal approach (MTSA) representing the two principal techniques. This systematic review and meta-analysis aimed to assess and compare the outcomes of ETSA and MTSA in treating PAs. A literature search was performed across PubMed, Scopus, Web of Science, and Cochrane Library. A total of 31 studies comprising 38,301 patients were included. The primary outcomes assessed were gross total resection (GTR) and cerebrospinal fluid (CSF) leak rates. Secondary outcomes encompass endocrine and surgical complications and mortality rates. Statistical analyses utilized R software, employing random-effects models. The analysis indicated insignificant differences in GTR rates between ETSA and MTSA (RR: 1.05, 95% CI [0.97, 1.15]) or in CSF leak rates (RR: 1.03, 95% CI [0.82, 1.31]). Meta-regression analysis revealed that nonfunctional tumors correlated with increased GTR rates, regardless of the surgical technique employed. No notable differences were detected in endocrine or surgical complications between the two methods. Notably, meta-regression analysis indicated that nonfunctional tumors and higher Knosp grade tumors are more likely to be completely resected. Moreover, larger preoperative tumor volume was significantly correlated with an increased risk of postoperative hypopituitarism. Nevertheless, a narrative review of total mortality demonstrated a higher rate in the MTSA group compared to the ETSA group (198 vs. 149 deaths), even with a larger patient cohort in the ETSA group. No publication bias was observed for GTR or CSF leak outcomes. ETSA and MTSA exhibit similar efficacy and safety profiles in treating PAs, with no significant differences in resection rates or complications. The findings highlight the necessity of personalized surgical planning, considering tumor characteristics and institutional expertise. Future research should prioritize long-term outcomes, patient-reported metrics, and the incorporation of emerging technologies to enhance surgical strategies for PAs.