Abstract
Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages. To determine if the proposed benefits of endoscopic resection are realized on a population level. We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions. Coarsened matching was applied to estimate the effects of surgical approach on complication rates, length of stay (LOS), costs, and likelihood of postoperative radiation. We found that LOS, readmission, and revision rates did not differ significantly between approaches. The overall complication rate was higher for endoscopy (47% compared to 39%, OR 1.37, 95% CI 1.22-1.53). Endoscopic approach was associated with greater risk of neurological complications (OR 1.32, 95% CI 1.11-1.55), diabetes insipidus (OR 1.65, 95% CI 1.37-2.00), and cerebrospinal fluid rhinorrhea (OR 1.83, 95% CI 1.07-3.13) compared to the microscopic approach. Although the total index payment was higher for patients receiving endoscopic resection ($32,959 compared to $29,977 for microscopic resection), there was no difference in long-term payments. Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery (OR 0.67, 95% CI 0.49-0.90) and intensity-modulated radiation therapy (OR 0.78, 95% CI 0.65-0.93). Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation. Although there are evident advantages to transsphenoidal endoscopy, our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.
Highlights
Sellar lesions such as pituitary adenomas, craniopharyngiomas, and Rathke’s cleft cysts were resected using a transsphenoidal approach with microscopy [1]
From 2007 to 2014, we identified 3,621 patients (54.5% female, median age 50 years) who received endoscopic surgery and 6,049 patients (52.7% female, median age 50 years) who received microsurgery for sellar lesions
We further observed an increase in total procedures during the duration of this study, with endoscopic surgery comprising a greater proportion of total procedures over time (Figure 1)
Summary
Sellar lesions such as pituitary adenomas, craniopharyngiomas, and Rathke’s cleft cysts were resected using a transsphenoidal approach with microscopy [1]. Since the introduction of endoscopic instruments and technique described by Jankowski et al in 1992, many institutions have reported a gradual transition to the endoscopic approach [2, 3]. Endoscopic vs Microscopic Resection of Sellar Lesions approach requires a nasal speculum to fracture the nasal septum and a sphenoidotomy to facilitate access to the anterior skull base. The endoscopic view is noted to provide a wider degree of freedom and improved visual access to the sella, limitations related to lens cleaning and “sword fighting” with instruments have been acknowledged [4]. Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages
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