Endocrine Outcomes and Complications After Endoscopic versus Microscopic Transsphenoidal Surgery for Pituitary...

Transsphenoidal surgery remains a principal treatment for most functioning and symptomatic non-functioning pituitary adenomas, but the relative endocrine and safety outcomes of endoscopic transsphenoidal surgery (ETS) and microscopic transsphenoidal surgery (MTS) remain debated. This systematic review and meta-analysis searched PubMed/MEDLINE, Embase, Web of Science Core Collection, Cochrane Library, Scopus, ClinicalTrials.gov, and reference lists for comparative studies published from January 2010 to March 2025. Eight studies comprising 769 patients were included in the endocrine-success analysis, with 392 patients treated by ETS and 377 by MTS. The pooled random-effects estimate favored ETS for the composite endocrine-success endpoint, defined as biochemical remission for functioning adenomas or preserved pituitary function in mixed and non-functioning cohorts (risk ratio [RR] 1.26, 95% confidence interval [CI] 1.13-1.41; I² = 17.8%). The functioning-only subgroup had an imprecise, non-significant estimate (RR 1.06, 95% CI 0.63-1.80), whereas mixed cohorts favored ETS (RR 1.22, 95% CI 1.11-1.34). Diabetes insipidus and cerebrospinal fluid (CSF) leak were infrequently reported and had wide CIs. New hypopituitarism was not meaningfully pooled because events were sparse and between-study heterogeneity was substantial; raw study-level counts are therefore presented. The available literature suggests an association between ETS and improved endocrine success, but interpretation is limited by heterogeneous outcome definitions, confounding by indication, and the predominance of retrospective cohorts. Complication outcomes remain underpowered, and no definitive conclusion can be drawn regarding differences in postoperative morbidity between approaches.