Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for the Role of Surgery for...

With the recent improvements in surgery, along with our ability to manage many pituitary tumors medically, the exact role of surgery for the treatment of functioning pituitary adenomas (PA) remains unclear. The purpose of this evidence-based clinical practice guideline was to determine the role of surgery in the treatment of functioning PA.

A systematic review of the literature was performed using the National Library of Medicine/PubMed database and Embase for studies relevant to the role of surgery in the treatment of patients with functioning PA. Clinical studies evaluating the role of trans-sphenoidal surgery vs medical management, endoscopic techniques vs microsurgery, the benefit of the use of adjunct surgical techniques to patient outcome, and the role of second surgery were selected for review.

The literature search yielded 7073 abstracts. Of these, 60 studies met inclusion criteria, and evidence-based guidelines were formulated on the use of surgical resection compared with medical management, the use of endoscopic techniques and/or other surgical adjunct techniques, and the benefit of reoperation for recurrent tumors compared with medical treatment and/or radiation.

Class III evidence suggests a benefit to surgery over medical management for growth hormone-secreting adenomas without evidence to support a benefit to pretreatment with a somatostatin analog before surgery. Class III evidence suggests a benefit to medical management over surgery in the treatment of patients with prolactinomas at primary diagnosis. There are insufficient data to support the benefit of endoscopic surgery compared with microscopic surgery, with or without additional adjuvant surgical techniques, for extent of surgical resection, hormone remission, length of stay, or complication rate, in the treatment of functional PA. There is a suggestion, however, that the endoscopic technique may be superior to the microscopic technique, for a shorter operative time and for extent of surgical resection and hormone remission rates for noninvasive pituitary macroadenomas. Similarly, there are insufficient data to support the use of reoperation for recurrent tumor compared with radiation and/or medical treatment.