Comparison of endoscopic versus microscopic transsphenoidal surgery in patients with pituitary adenomas: a propensity score matched study.

Background: The comparative efficacy of endoscopic versus microscopic transsphenoidal surgery for patients with pituitary adenoma (PA) remains controversial. Previous retrospective studies have often been limited by inconsistencies in baseline characteristics of patients, which may affect the validity of the comparisons. This study aimed to evaluate the trend in the proportion of transsphenoidal endoscopic and microscopic surgeries in China and compare outcomes in comparable patients.

Materials and methods: The National Brain Tumor Registry of China (NBTRC) database was queried to extract PA patients (2011-2021) for trend analysis. Stratified sampling was performed, and a 1:1 propensity score matching (PSM) was used to balance the patients' baseline characteristics. Postoperative outcomes, complications, and prognosis were compared.

Results: Among the nationwide 17 012 PA patients, there was a gradual increase in the proportion of endoscopic surgeries (annual percent change, 11.89%). Among the 1863 stratified patients, those who underwent endoscopic surgery had a higher preoperative recurrence rate and higher Knosp and Hardy grades (P < 0.05). Endoscopic surgery showed a similar gross total resection (GTR) rate to microscopy (55.6% vs. 54.9%, P = 0.886) in the real-world cohort and a higher GTR rate (59.5% vs. 54.3%, P = 0.037) in the PSM cohort. After PSM, there was no significant difference in cerebrospinal fluid leak and secondary surgery (P > 0.05); endoscopic surgery showed more bleeding, longer surgical time, shorter hospital stay, and higher costs (all P < 0.001) compared to microscopic surgery. The risk of postoperative progression was similar between endoscopic and microscopic surgeries for comparable PA patients (P = 0.45).

Conclusion: Endoscopic transsphenoidal surgery is increasingly adopted in China, demonstrating a higher GTR rate than microscopic transsphenoidal surgery in PA patients with similar characteristics, without increasing severe complication rates. The risk of postoperative progression was similar between the two techniques.