Learning Curve in Endoscopic Pituitary Surgery: Is Progress over Time Always Guaranteed? A Consecutive Series of 123...

Objectives: To characterize the learning curve of endoscopic transsphenoidal pituitary adenoma surgery performed by a single neurosurgeon, assess how operative time, resection rates, and clinical outcomes evolved with experience, and identify tumor-related factors influencing surgical performance. Methods: This retrospective study included 123 consecutive endoscopic transsphenoidal pituitary adenoma resections performed between 2018 and 2025. Cases were divided into quartiles according to chronological order. Clinical, radiological, endocrinological, and operative variables were analyzed. Gross total resection (GTR), biochemical remission, postoperative complications, and visual and cranial nerve outcomes were compared between quartiles. A segmented linear regression model was applied to identify changepoints in the operative-time learning curve. Statistical significance was set at p < 0.05. Results: The mean operative time decreased by 31.8%, from 160.8 min in Quartile 1 to 109.7 min in Quartile 4. Segmented regression revealed two changepoints at cases 47 and 85, defining three learning phases: a steep improvement phase, a consolidation phase, and a plateau. GTR was achieved in 51.2% of patients and did not significantly differ across quartiles. For Knosp 0-2 tumors, GTR was 76.1% overall; for Knosp 3-4 tumors, 30%. Tumor diameter, Knosp grade, and sphenoid sinus invasion were strongly associated with lower GTR rates (all p < 0.05). Biochemical remission was achieved in 74.2% of patients with functional adenomas. New or worsened postoperative pituitary insufficiency significantly decreased across quartiles (p < 0.001). Rates of postoperative diabetes insipidus (30.8%) and CSF leak (6.5%) were comparable with published literature and showed no consistent temporal trend. Conclusions: A clear learning curve exists in endoscopic pituitary surgery, with operative proficiency achieved after approximately 50 cases and an experienced plateau after ~90 cases. Surgical experience significantly reduced operative time and postoperative pituitary insufficiency but did not influence GTR rates, likely due to a high and increasing proportion of large tumors with cavernous sinus invasion. Tumor size, Knosp grade, and sphenoid sinus invasion were identified as major determinants of surgical complexity and should be accounted for when evaluating learning curves and surgical outcomes.