Incidence and predictors of complications, readmission, and reoperation following endoscopic transsphenoidal surgery for pituitary adenomas

Endoscopic transsphenoidal surgery (eTSS) is a common neurosurgical procedure used to treat pituitary adenomas (PAs). The authors evaluated the incidence of complications, early readmission, and early reoperation following eTSS for PAs and identified clinical, surgical, and tumor characteristics predictive of these outcomes.

The data of all patients with histologically confirmed PAs who underwent eTSS at the authors' institution between May 2011 and September 2024 were retrospectively reviewed. Thirty-day postoperative complications were grouped into surgical and medical categories. Early readmission and early reoperation were defined as occurring within 90 days of discharge and surgery, respectively.

A total of 709 endoscopic transsphenoidal operations (655 direct and 54 extended approaches) were performed in 693 patients. The median tumor diameter (IQR) was 24 (17-32) mm, and 656 cases (93%) were macroadenomas. Cavernous sinus invasion on MRI was noted in 32.2% of cases. Fifteen percent were reoperations. Gross-total resection was achieved in 63.5% of patients, and the median length of stay was 3 days. Surgical complications included postoperative CSF leakage (4.2%), epistaxis (2.7%), cranial nerve palsy (1.0%), worsened vision (1.0%), meningitis (1.0%), stroke (0.8%), hydrocephalus (0.7%), hematoma (0.6%), sinusitis (0.6%), abdominal hematoma or infection (0.4%), carotid artery injury (0.1%), and death (0.3%). Medical complications included transient diabetes insipidus (8.7%), permanent diabetes insipidus (2.4%), bacteremia/sepsis (0.7%), pneumonia (0.3%), and deep venous thrombosis/pulmonary embolism (0.1%). Early readmission and early reoperation were observed in 10.2% and 4.8% of cases, respectively. The most common reasons for early readmission were delayed hyponatremia (4.2%), CSF leakage (1.8%), infection (1.1%), epistaxis (0.7%), and hypocortisolemia (0.1%), while the most common reasons for early reoperation were CSF leakage (2.5%), residual tumor (1.3%), worsened vision (0.6%), infection (0.6%), and hematoma (0.3%). Predictors of complications included increasing tumor diameter, firm tumor consistency, the presence of an intraoperative CSF leak, and use of an extended approach. While not statistically significant, rates of postoperative CSF leakage (5.1% vs 3.4%), early readmission (11.4% vs 9.1%), and early reoperation (5.7% vs 4.0%) decreased from the first half of the cohort to the second half of the cohort.

Endoscopic TSS for PAs is associated with low morbidity and mortality, although a number of complications are possible. Readmission and reoperation following eTSS occur less frequently when endocrine readmissions can be averted. The results of this study provide information on the risks associated with eTSS and serve as a guide for neurosurgeons to counsel patients undergoing this procedure.