Endoscopic endonasal surgery for prolactin-secreting adenoma: a retrospective multicenter study by the neuroendoscopy section of the Italian Society of Neurosurgery.
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OBJECTIVE: Although dopamine agonist (DA) therapy still represents the standard of care for prolactinomas, a reconsideration of the role of transsphenoidal surgery has been promoted in recent years. The aim of this multicenter retrospective study was to assess the short- and long-term results of the endoscopic endonasal approach (EEA) for prolactinomas, analyzing which factors have a favorable prognostic role. METHODS: All consecutive prolactinomas operated on in 12 Italian neurosurgical centers between 2013 and 2023 were included. For each case, preoperative clinical and neuroradiological features were considered, as well as surgical complications and short- and long-term results. RESULTS: The series included 215 patients (44.2% males, mean age 39.7 [SD 16.6] years), accounting for 4.5% of all pituitary surgeries in these centers. The majority of prolactinomas (67.9%) were macroprolactinomas. Radical tumor resection was achieved in 171 patients (79.5%), and 3-month biochemical remission in 154 patients (71.6%). The most common surgical complication was postoperative CSF leak (2.8%). Endocrinological sequelae consisted of new onset of anterior hypopituitarism in 10.7% of cases, transient diabetes insipidus (DI) in 3.3%, and permanent DI in 2.3%. Long-term remission (mean follow-up 33.5 [SD 25.0] months) was achieved in 75.4% of patients, 14 patients (6.5%) presented with tumor recurrence/progression, and 1 (0.5%) demonstrated tumor evolution to carcinoma. CONCLUSIONS: The EEA is a valid option for the treatment of prolactinomas, with better results for micro tumors and regular macro tumors. This study found that preoperative prolactin values < 184 ng/ml were associated with higher chances of biochemical remission, as was larger pituitary surgery center volume. Currently, the most common surgical indications for prolactinomas are represented by cases that are not responsive or intolerant to DAs. However, interesting future perspectives considering EEA as a possible co-first-line therapy in selected patients have been recently proposed.