Endocrine and surgical outcomes after medial cavernous sinus wall resection for functioning pituitary adenomas: a...

Functioning pituitary adenomas (FPAs) require both cytoreduction and durable endocrinological remission (ER), which is often limited by occult invasion of the medial cavernous sinus wall. Selective medial cavernous sinus wall resection (MCSWR) has emerged as a targeted approach, but its endocrine benefits and safety profile remain incompletely understood. We synthesize syndrome-specific remission, resection, recurrence, and complication rates after MCSWR in adults with FPAs. We conducted a systematic review and meta-analysis of PubMed, Scopus, and Embase through 2025, including adults with GH-, ACTH-, and prolactin-secreting adenomas who underwent intentional medial cavernous sinus wall resection as described by the original studies and had at least one postoperative endocrine outcome. Two reviewers extracted study- and tumor-level data on resection, ER, recurrence, and complications. Pooled event rates were estimated with random-effects models. Thirteen studies (11 retrospective, 2 prospective) involving 493 patients met inclusion criteria. Among 344 patients with available endocrine follow-up, pooled ER was 85% (95% CI:77-91%), and gross total resection (GTR) was 92% (95% CI:81-97%). Recurrence occurred in 6% (95% CI:3-13%). Subgroup ER rates were 87% for acromegaly, 89% for Cushing's disease, and 78% for prolactinomas, with corresponding GTR rates of 95%, 91%, and 80%. Complications were rare: ICA injury 0%, cranial nerve III and VI palsies 3% each, and postoperative CSF leak 4%. Most studies had a serious or critical risk of bias, mainly due to confounding and single-arm designs. Follow-up ranged from 9 to 30 months in contributing cohorts, with earlier series reporting ranges up to 1-49 months. MCSWR was associated with high reported ER and GTR rates, low reported recurrence, and acceptable morbidity in carefully selected patients with FPAs, particularly somatotroph and corticotroph tumors. However, the evidence mainly comes from high-volume centers and non-comparative series with limited follow-up, highlighting the need for prospective, multicenter studies with standardized endocrine endpoints, histological confirmation, and long-term follow-up.