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Updated: Jul 12, 2026
Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas
Published on: January 17, 2018
Accuracy of Surgeon's Estimate of Gross Total Resection After Endoscopic Endonasal Trans-sphenoidal Surgery for
Jesse D Lawrence1, Parsa Nilchian2, Jeffrey Shi2
1Department of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA.
Background And Objectives:
While a surgeon's intraoperative assessment of gross total resection (GTR) has been used to predict recurrence in benign tumors such as meningiomas, its accuracy in pituitary adenoma surgery remains unclear. This study compares intraoperative assessment with postoperative MRI in predicting extent of resection (EOR) and recurrence in patients undergoing endoscopic endonasal resection of nonfunctioning pituitary macroadenomas.
Methods:
A retrospective review was performed on 327 consecutive patients with non-hormone-producing pituitary adenomas resected by a single surgeon. At the conclusion of each operation, the surgeon recorded the intraoperative assessment of EOR. All patients underwent pre- and postoperative MRI, and EOR was independently assessed by neuroradiology. Radiographic recurrence and additional treatment need were correlated with intraoperative assessment and postoperative MRI findings.
Results:
Intraoperatively, the surgeon overestimated GTR rates. While intraoperative assessment GTR was reported in 90%, MRI revealed GTR in 72%. The positive predictive value of intraoperative assessment was 74% and the negative predictive value was 84%. After 40.7 months of mean follow-up, there was a 16.7% recurrence rate. Patients with intraoperative assessment GTR and subtotal resection (STR) recurred at rates of 14% and 39%, respectively. Patients with radiographic GTR and STR recurred at rates of 6% and 44%. Discordant cases with intraoperative assessment GTR and MRI STR (n = 57) recurred at 42%, indicating MRI was a more accurate recurrence predictor. Discordant cases with intraoperative assessment STR and MRI GTR (n = 6) recurred at a rate of 0%, indicating the higher accuracy of postoperative MRI. The sensitivity and specificity of intraoperative assessment for predicting recurrence were 24% and 93%, respectively. Both sensitivity and specificity of postoperative MRI for predicting recurrence were 78%.
Conclusion:
Postoperative MRI was more accurate at establishing GTR, identifying residual tumor, and predicting recurrence compared with the surgeon's intraoperative assessment. This study supports the limited value of intraoperative EOR assessment compared with imaging.
