Surgical treatment of pituitary tumours

The surgical treatment of pituitary tumours underwent considerable evolution during the past centennial. Since Schloffer's first description, excellent surgeons refined the surgical techniques, utilised hormonal measurements and imaging investigations at different times to define surgical success or failure. To date, transsphenoidal surgery is the approach of choice for over 90% of pituitary tumours, but still transcranial operations are needed even in experienced hands when asymmetrical and large pituitary tumours with minor intrasellar components present. When the indication for surgery stands, the complication rate to date is relatively low, particularly if the surgeon and his or her centre have sufficient experience in the field. In microadenomas, the success rate reported from expert authors approaches 90%. Generally speaking, patients with non-functioning pituitary adenomas, acromegaly, thyrotropinomas and Cushing's disease are excellent candidates for primary surgical treatment. Re-operations are generally associated with less favourable outcomes. In prolactinomas, the primary therapy is medical; however, when dopamine agonists are not well tolerated or inefficient, an operative treatment should be considered. Although alternative medical treatments exist in acromegaly and thyrotropinomas, surgical treatment is relatively cheap. The implementation of endoscope-assisted, entirely endoscopic, image-guided surgery and intra-operative magnetic resonance (MR) imaging, particularly in combination with utilisation of the established microsurgical techniques, extends the surgical spectrum. Lesions become surgically accessible, which one did not dare to touch even a century ago. Moreover, it seems that the patient's safety has increased and more patients have their tumours completely resected, which is equivalent to a higher remission rate in hormonally active tumours.