Acta Neurochirurgica

, Volume 160, Issue 5, pp 1005–1021 | Cite as

Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis

  • Reem D. Almutairi
  • Ivo S. Muskens
  • David J. Cote
  • Mark D. Dijkman
  • Vasileios K. Kavouridis
  • Erin Crocker
  • Kholoud Ghazawi
  • Marike L. D. Broekman
  • Timothy R. Smith
  • Rania A. Mekary
  • Hasan A. Zaidi
Review Article - Brain Tumors



Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS.


A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines.


Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I2 = 92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I2 = 84.0%) in a fixed-effect model (P-interaction < 0.01). For functioning pituitary adenomas (FPAs) (n = 1170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I2 = 63.9%) and mTSS (GTR=75.5%; I2 = 79.0%); (P-interaction = 0.92). For nonfunctioning pituitary adenomas (NFPAs) (n = 2655 patients), eTSS (GTR=71.0%; I2 = 86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I2 = 87.5%) in a fixed-effect model (P-interaction < 0.01). None of the associations were significant in a random-effect model (all P-interaction > 0.05). No significant publication bias was identified for any of the outcomes.


Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.


Endoscopic transsphenoidal surgery Gross total resection Meta-analysis Microscopic transsphenoidal surgery Pituitary adenoma Transsphenoidal surgery 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

701_2017_3438_MOESM1_ESM.docx (134 kb)
ESM 1 Search Strategy (DOCX 134 kb)
701_2017_3438_MOESM2_ESM.docx (30 kb)
ESM 2 Studies excluded in the Analysis of Gross Tumor Resection (GTR). CS, Case series; RT, Randomized Trail; ETSS, Endoscopic Transsphenoidal surgery; MTSS, Microscopic Transsphenoidal Surgery; EATSS, Endoscope-Assisted Endonasal Trans-sphenoidal microsurgery; PA, Pituitary Adenomas; GTR, Gross Tumor Resection; NS, Not specified; NA, Not Available; (DOCX 30 kb)
701_2017_3438_MOESM3_ESM.docx (41 kb)
ESM 3 Analysis of Gross Tumor Resection (GTR) In Pituitary Adenoma Patients according to Tumor Characteristic in the selected studies. ETSS, Endoscopic Transsphenoidal surgery; MTSS, Microscopic Transsphenoidal Surgery; PA, Pituitary Adenomas; GTR, Gross Tumor Resection; NA, No Available; FPA, Functional Pituitary Adenoma; NFPA, Non- Functional Pituitary Adenoma ACTH, Cushing Disease; PRL, Prolactinoma; GH, Growth Hormone Hypersecretion (DOCX 41 kb)
701_2017_3438_MOESM4_ESM.png (55 kb)
ESM 4 Funnel plot for publication bias for overall pituitary adenoma (PNG 55 kb)
701_2017_3438_MOESM5_ESM.png (40 kb)
ESM 5 Funnel plot for publication bias for functional pituitary adenoma (PNG 39 kb)
701_2017_3438_MOESM6_ESM.png (51 kb)
ESM 6 Funnel plot for publication bias for non-functional pituitary adenoma (PNG 51 kb)


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Reem D. Almutairi
    • 1
    • 2
  • Ivo S. Muskens
    • 3
    • 4
  • David J. Cote
    • 4
  • Mark D. Dijkman
    • 3
  • Vasileios K. Kavouridis
    • 4
  • Erin Crocker
    • 4
  • Kholoud Ghazawi
    • 1
  • Marike L. D. Broekman
    • 3
    • 4
  • Timothy R. Smith
    • 4
  • Rania A. Mekary
    • 1
    • 4
  • Hasan A. Zaidi
    • 4
  1. 1.Department of Pharmaceutical Business and Administrative SciencesMCPHS UniversityBostonUSA
  2. 2.School of PharmacyPrincess Nourah bint Abdulrahman UniversityRiyadhSaudi Arabia
  3. 3.Brain Center Rudolf MagnusUtrecht University Medical CenterUtrechtThe Netherlands
  4. 4.Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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