European Journal of Cardiovascular Medicine

Visual impairment, endocrine dysfunction, or symptoms associated to mass effect are common presentations of pituitary macroadenomas, which make up a significant fraction of sellar and suprasellar lesions. The gold standard for removing these tumors is still transsphenoidal surgery, which allows for direct sellar access with minimum brain retraction. As far back as anyone can remember, the gold standard for adenoma excision has been the microscopic transsphenoidal approach [1-3].

Endoscopic transsphenoidal surgery is a game-changer in skull base surgery that has only been around for 20 years. Endoscopic surgery has the ability to remove tumors more safely and thoroughly because of its panoramic vision, better lighting, and increased visibility of suprasellar and parasellar extensions. There may be less blood loss, less surgical trauma, and quicker postoperative recovery due to the endoscopic corridor's minimally intrusive design [4-6].

In spite of these potential benefits, the endoscopic method's relative merits in comparison to the more traditional microscopic approach are still up for discussion. There are still worries about the increased rates of cerebrospinal fluid (CSF) leaks, the technical complexity, and the necessity for advanced surgical expertise, even though endoscopy has been shown in multiple non-randomized studies to improve visualization and raise resection rates. Despite their scarcity, randomized controlled trials (RCTs) provide the strongest evidence for comparing the two methods head-to-head [7-9].

A meta-analysis of randomized trials is necessary to compare endoscopic and microscopic transsphenoidal surgery for pituitary macroadenomas, as there is still much debate over which method is better and there is a lack of high-quality comparative data. To help doctors better grasp the advantages and limits of both methods, this study comprehensively reviews evidence from RCTs to compare the two strategies in terms of surgical results, endocrine remission, visual improvement, and complication profiles.

This study was performed as a comprehensive review and meta-analysis of randomized controlled trials (RCTs) that compared endoscopic and microscopic transsphenoidal surgery for pituitary macroadenomas. The technique adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards.

Study Selection:

Two independent reviewers examined all titles and abstracts. Full-text articles that met the eligibility criteria were obtained for comprehensive assessment. Consensus or the intervention of a third reviewer settled disagreements. Researchers looked at 50 patients from the RCTs that were included.

Inclusion Criteria:

• Randomized controlled trials (RCTs)
• Adult patients diagnosed with pituitary macroadenoma
• Comparison between endoscopic and microscopic transsphenoidal surgical approaches
• Studies reporting at least one primary or secondary outcome listed above

Exclusion Criteria:

• Non-randomized studies, retrospective studies, case series, or case reports
• Studies including microadenomas without separate analysis
• Purely radiological or cadaveric studies
• Inadequate data for extraction
• Duplicate publications
• Non-English language publications

Statistical Analysis:

The statistical approach for this meta-analysis utilized Review Manager (RevMan) and SPSS where necessary. A fixed-effects model was utilized in scenarios of low heterogeneity, whereas a random-effects model was employed in cases of moderate to high heterogeneity. We fixed the level of statistical significance at p < 0.05. Funnel plot analysis was used to look for publication bias when there were ten or more studies, and sensitivity analysis was done by taking out one study at a time to see how strong the results were.

The meta-analysis includes 50 patients from randomized controlled trials. Twenty-six patients had endoscopic transsphenoidal surgery, while twenty-four had the microscopic technique. The results from all the studies are shown below.

Table 1. Baseline Characteristics of Included Patients

Table 1 illustrates that the two groups were similar in terms of age, sex, tumor size, and how they looked at the start of the study.

Table 2. Surgical Outcomes

                          *Significant

Table 2 shows that the endoscopic group had better perioperative outcomes, such as less blood loss and shorter hospital stays. Even though endoscopic surgery had a greater gross total resection rate, the difference was not big enough to be statistically significant.

Table 3. Visual and Endocrine Outcomes

Table 3 demonstrates that the endoscopic group had larger visual improvements, but this was not statistically significant. The rates of hormonal remission were similar for both surgical methods.

Table 4. Postoperative Complications

Table 4 shows that both methods had the same number of complications. There was a little difference in the number of CSF leaks between the endoscopic group and the other group, but it was not statistically significant. The rates of complications were similar overall.

Table 5. Meta-Analytic Summary of Effect Sizes

                            *Statistically significant

Summarized in Table 5 are the pooled effect sizes. In terms of intraoperative blood loss and length of hospital stay, endoscopic surgery was found to have significant advantages. There was no statistically significant difference in the other endpoints, such as visual improvement, CSF leak, or gross total resection.

The current meta-analysis of randomized controlled trials assessed the relative efficacy of endoscopic versus microscopic transsphenoidal surgery for pituitary macroadenomas. The study included 50 patients, which made it possible to compare clinical results, surgical parameters, and complication profiles between the two surgical methods in a focused way. The results show that the endoscopic technique has significant benefits in the perioperative period while keeping the rates of endocrine and visual outcomes the same [10-12].

One of the most important things this study found is that the endoscopic group had a lot less blood loss during surgery. This is in line with what is already known about the benefits of endoscopic procedures, which offer better lighting and a wider view, making surgical dissection more accurate and cutting down on superfluous tissue manipulation. Patients who had endoscopic surgery also had much shorter hospital stays, which shows that they recovered from surgery faster and felt less pain afterward. These findings align with other prospective and retrospective studies that emphasize the minimally invasive benefits of the endoscopic corridor [13-15].

The combined data showed a trend toward higher gross total resection (GTR) rates with the endoscopic technique, but this difference was not statistically significant. This tendency may be due to the better images that endoscopy provides, especially when it comes to suprasellar and parasellar tumor expansions. Nonetheless, the absence of statistical significance may be attributed to the small sample size, the restricted number of randomized trials, and the diversity in tumor shape among studies. In the same way, visual improvement happened more often following endoscopic surgery, which means that the optic apparatus was better decompressed. However, the difference was not statistically significant [16-19].

The endocrine results were largely the same for both methods. Hormonal remission rates shown no significant difference, indicating that both surgical techniques are comparably efficient in excising hormonally active tumors or alleviating bulk influence on the pituitary gland. This may also mean that hormonal stability after surgery is affected by more than just how well the surgeon can see the tumor, such as the type of tumor, the patient's endocrine status before surgery, and how well the gland is preserved [20-23].

The complication profiles of the two groups were comparable, with no statistically significant changes. The incidence of CSF leak was marginally elevated post-endoscopic surgery; however, this observation was not statistically significant and aligns with previous studies indicating that CSF leak rates often diminish as the surgeon's proficiency with endoscopic methods increases. The overall complication rates remained identical, emphasizing the safety of both techniques when performed by experienced surgeons [24-26].

This meta-analysis' results are useful, but they should be read with some caveats in mind. There are only a few randomized trials available, which means that the sample size is not very large. Differences in surgical skill, tumor kind, reconstructive methods, and postoperative care among studies may potentially add to the differences. This analysis offers significant insights into the comparative efficacy of endoscopic and microscopic techniques, grounded in the most reliable randomized evidence [26, 27].

To sum up, the results show that endoscopic transsphenoidal surgery has a number of benefits before and after surgery, such as less blood loss and a shorter hospital stay, without affecting the rates of resection, visual outcomes, or endocrine recovery. The results indicate the increasing use of endoscopic methods as a safe and effective replacement for the traditional microscopic method for treating pituitary macroadenomas [27, 28].

This meta-analysis of randomized controlled studies shows that endoscopic transsphenoidal surgery has many important benefits over the standard microscopic method for pituitary macroadenomas. The endoscopic method resulted in markedly diminished intraoperative blood loss and a shortened duration of hospitalization, indicating decreased surgical trauma and expedited postoperative recovery. There was a tendency for endoscopy to lead to higher gross total resection rates and better visual improvement, but these differences were not statistically significant. The endocrine outcomes and overall complication rates were similar for both methods, which means that both are safe and work well when done by skilled surgeons. In general, endoscopic transsphenoidal surgery is a safe and useful alternative to the microscopic procedure. It could help patients recover faster and make the surgery more efficient.

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