Complications in endoscopic endonasal surgery for pituitary neuroendocrine tumors: an Italian multicenter study

The primary aim of this Italian multicenter study was to determine the incidence of complications associated with pituitary neuroendocrine tumor (PitNET) removal in the modern era of endoscopic pituitary surgery. The secondary objective was to evaluate the influence of surgical experience, patients, and tumor features on the occurrence of each specific complication, as well as options for management and avoidance.

This retrospective study included the contributions of 10 Italian neurosurgical departments. Respondents were asked to provide the number of endoscopic endonasal approaches (EEAs) performed for PitNET removal from 2013 to 2023 and to identify any surgical complications observed. Main tumor and surgical features associated with the occurrence of surgical complications were evaluated. Respondents were placed into 3 surgical experience groups, based on the number of endoscopic PitNET removals performed during the study period.

From a total of 3356 operations for PitNET removal via an EEA, the incidence of surgical complications was 11.92% (400/3356). Worsening of anterior pituitary function (4.80%) and permanent diabetes insipidus (2.32%) were the complications that occurred the most often. Postoperative CSF leak occurred in 50 cases (1.49%). Other significant complications, such as carotid artery injury, epistaxis, sphenoid sinusitis, septal perforation, residual tumor hemorrhage, intracranial hematoma, vasospasm, subarachnoid hemorrhage, cranial nerve injuries, visual worsening, meningitis, and tension pneumocephalus occurred with incidence rates between 0.06% and 0.89%. Among 350 patients experiencing at least one surgical complication, 58.86% harbored a nonfunctioning adenoma and 17.71% a recurrent tumor. The overall rate of postoperative complications in relation to surgical experience exhibited a U-shaped progression, with a significantly higher rate (p < 0.001) in centers performing fewer than 200 procedures (117/654, 17.89%) compared to centers performing 200-500 operations (88/900, 9.78%) and those with caseloads exceeding 500 (195/1802, 10.82%).

This study demonstrated a reduced overall rate of complications in EEAs for PitNET removal related to advancements in surgical technique, technological progress, and surgeon experience, which have allowed an expansion of indications to more complex cases. Within the U-shaped relationship between surgical experience and complication rate, likely due to the prevalence of PitNETs at higher risk of surgical morbidity in centers with more experience, CSF leakage was found to be the only complication continuously improving with surgical experience.