Abstract
PurposeSystematic review and meta-analysis comparing endoscopic and microscopic transsphenoidal surgery for Cushing’s disease regarding surgical outcomes (remission, recurrence, and mortality) and complication rates. To stratify the results by tumor size.MethodsNine 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.ResultsWe included 97 articles with 6695 patients in total (5711 microscopically and 984 endoscopically operated). Overall, remission was achieved in 5177 patients (80%), with no clear difference between both 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 (11.3 vs. 21.7%). 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 lower after endoscopic surgery (1.5 vs. 17.0%).ConclusionsEndoscopic surgery for patients with Cushing’s disease reaches comparable results for microadenomas, and probably better results for macroadenomas than microscopic surgery. This is present despite the presumed learning curve of the newer endoscopic technique, although confounding cannot be excluded. Based on this study, endoscopic surgery may thus be considered the current standard of care. Microscopic surgery can be used based on neurosurgeon’s preference. Endocrinologists and neurosurgeons in pituitary centers performing the microscopic technique should at least consider referring Cushing’s disease patients with a macroadenoma.
Highlights
Cushing’s disease is caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma, with an estimated incidence of 1.2–2.4 per million each year [1]
There were no clear differences between surgical techniques regarding mortality, or remission rates after repeat transsphenoidal surgery
Complication rates ranged from 0.1% to 21.7%, with minor differences between surgical techniques
Summary
Cushing’s disease is caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma, with an estimated incidence of 1.2–2.4 per million each year [1]. The resulting excess of glucocorticoids induces insulin resistance, dyslipidemia, central obesity, hypercoagulability, and increases the risk of osteoporosis, hypertension, and neuropsychiatric disorders [2, 3]. First-choice treatment for Cushing’s disease is transsphenoidal pituitary surgery, with selective adenoma removal [4]. Mortality risk in Cushing’s disease patients remains increased [5]. Two main techniques have been used for transsphenoidal pituitary surgery: microscopic and endoscopic surgery
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