Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study
Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study
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DOI：
10.3171/2018.11.jns181238
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发表时间：
2020-04-01
影响因子：
4.1
通讯作者：
Mayberg, Marc R.
中科院分区：
文献类型：
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作者：
Little, Andrew S.;Kelly, Daniel F.;Mayberg, Marc R.
许多外科医生在治疗无功能垂体肿瘤时采用完全内窥镜手术而不是显微经蝶窦手术，尽管没有高质量的证据表明内窥镜手术的患者预后更好。本分析的目的是在一项前瞻性多中心对照研究中比较这些技术。方法比较成人无功能腺瘤经内镜或镜下经蝶窦手术后肿瘤切除的程度。主要终点是术后MRI确定的肿瘤总切除。次要终点包括肿瘤切除的体积范围、垂体激素结果和标准质量测量。结果7家垂体中心和15名外科医生参与了研究。在筛查的530名患者中，有260名患者在2015年2月至2017年6月期间入组（82人接受了显微镜检查，177人接受了内窥镜检查，1人取消了手术）。使用显微技术的外科医生比使用内窥镜技术的外科医生在实践年数和经蝶窦手术次数方面更有经验（p < 0.001）。80.0%（60/75）的显微手术患者和83.7%（139/166）的内镜手术患者实现了总切除（p = 0.47, OR 0.8, 95% CI 0.4-1.6）。两组之间的体积切除范围、住院时间、手术相关死亡和意外再入院率相似（p < 0.05）。28.4%（19/67）的显微手术患者和9.7%（14/145）的内镜手术患者在6个月时出现新的激素缺乏（p < 0.001, OR 3.7, 95% CI 1.7-7.7）。镜下手术时间明显短于内镜下手术时间（p < 0.001）。结论：经验丰富的外科医生进行显微手术和经验不足的外科医生进行内窥镜手术在无功能垂体腺瘤患者中获得了相似的肿瘤切除程度和高质量的预后。内镜技术可能与较低的术后垂体功能障碍率有关。虽然这两种技术的手术结果总体上是可以接受的，但本研究总体上支持由熟练的外科医生进行垂体内窥镜手术。问题类型：治疗性；研究设计：前瞻性队列试验；证据：III类。
OBJECTIVE Many surgeons have adopted fully endoscopic over microscopic transsphenoidal surgery for nonfunctioning pituitary tumors, although no high-quality evidence demonstrates superior patient outcomes with endoscopic surgery. The goal of this analysis was to compare these techniques in a prospective multicenter controlled study.METHODS Extent of tumor resection was compared after endoscopic or microscopic transsphenoidal surgery in adults with nonfunctioning adenomas. The primary end point was gross-total tumor resection determined by postoperative MRI. Secondary end points included volumetric extent of tumor resection, pituitary hormone outcomes, and standard quality measures.RESULTS Seven pituitary centers and 15 surgeons participated in the study. Of the 530 patients screened, 260 were enrolled (82 who underwent microscopic procedures, 177 who underwent endoscopic procedures, and 1 who cancelled surgery) between February 2015 and June 2017. Surgeons who used the microscopic technique were more experienced than the surgeons who used the endoscopic technique in terms of years in practice and number of transsphenoidal surgeries performed (p < 0.001). Gross-total resection was achieved in 80.0% (60/75) of microscopic surgery patients and 83.7% (139/166) of endoscopic surgery patients (p = 0.47, OR 0.8, 95% CI 0.4-1.6). Volumetric extent of resection, length of stay, surgery-related deaths, and unplanned readmission rates were similar between groups (p > 0.2). New hormone deficiency was present at 6 months in 28.4% (19/67) of the microscopic surgery patients and 9.7% (14/145) of the endoscopic surgery patients (p < 0.001, OR 3.7, 95% CI 1.7-7.7). Microscopic surgery cases were significantly shorter in duration than endoscopic surgery cases (p < 0.001).CONCLUSIONS Experienced surgeons who performed microscopic surgery and less experienced surgeons who performed endoscopic surgery achieved similar extents of tumor resection and quality outcomes in patients with non-functioning pituitary adenomas. The endoscopic technique may be associated with lower rates of postoperative pituitary gland dysfunction. This study generally supports the transition to endoscopic pituitary surgery when the procedure is performed by proficient surgeons, although both techniques yield overall acceptable surgical outcomes.CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: prospective cohort trial; evidence: class III.