Endocrine Abstracts (2018) 56 GP202 | DOI: 10.1530/endoabs.56.GP202

Endoscopic vs microscopic transsphenoidal surgery for Cushing's disease: a systematic review and meta-analysis

Leonie H A Broersen1,2, Nienke R Biermasz1,2, Wouter R van Furth2,3, Friso de Vries1,2, Marco J T Verstegen2,3, Olaf M Dekkers1,4 & Alberto M Pereira1,2


1Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands; 2Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, The Netherlands; 3Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands; 4Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.


Background: Cushing’s disease is caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma, resulting in glucocorticoid excess. First-choice treatment is transsphenoidal pituitary surgery, using either a microscopic or endoscopic technique. Convincing evidence supporting the choice for one of both techniques, either based on treatment results or complication rate, is lacking.

Objective: We aimed to compare endoscopic and microscopic transsphenoidal surgery for Cushing’s disease regarding surgical outcomes (remission, recurrence, and mortality) and complication rates, and to stratify the results by tumor size.

Methods: Nine electronic databases were searched in February 2017 to identify potentially relevant articles. Cohort studies assessing surgical outcomes or complication rates after endoscopic or microscopic transsphenoidal surgery for Cushing’s disease were eligible. Pooled proportions were reported including 95% confidence intervals.

Results: We included 97 articles with a total of 6695 patients (5711 microscopically and 984 endoscopically operated). Overall, remission was achieved in 5177 patients (80%), with no clear difference between the two techniques. Recurrence was around 10% and short term mortality <0.5% for both techniques. Cerebrospinal fluid leak occurred more often in endoscopic surgery (12.9% vs 4.0%), whereas transient diabetes insipidus occurred less often (10.4% vs 18.5%). For microadenomas, results were comparable between both techniques. For macroadenomas, the percentage of patients in remission was higher after endoscopic surgery (76.3% vs 59.9%), and the percentage recurrence was lower after endoscopic surgery (1.5% vs 17.0%).

Conclusion: This meta-analysis shows that for patients with Cushing’s disease endoscopic surgery reaches comparable results for microadenomas, and probably better results for macroadenomas than microscopic surgery. These results are obvious despite the presumed learning curve of the newer endoscopic technique, although confounding cannot be excluded. Based on this study, the endoscopic technique may be considered the current standard of care, microscopic neurosurgical pituitary centers should at least consider referring Cushing’s disease patients with a macroadenoma.

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