The clinical course of pituitary adenoma is highly variable. Aggressive adenoma subtypes may require multimodal therapy with multiple operations. Even standard adenoma exhibit a relatively high long term recurrence rate and delayed intervention is often required. The indications for revision surgery in the endoscopic era are expanding for both functioning and non-functioning tumours, including access to the medial and lateral cavernous sinus and intracranial compartments. Although revision surgery can be challenging anatomically, it has been demonstrated to be safe and effective. Risk factors for complications in repeat surgery include prior radiotherapy. Therefore, the question of early radiotherapy in pituitary adenoma remains controversial. Increasing understanding of pituitary tumour biology will facilitate individualised treatment and surveillance protocols, with early intervention in high risk adenoma subtypes.