Outcomes of the Endoscopic Endonasal Approach for Nonfunctional Pituitary Adenomas in Elderly Patients

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Background: The incidence of pituitary adenomas rises with age, leading to increased overall prevalence. Understanding the role of surgery for nonfunctional pituitary adenomas (NFPAs) in the elderly, especially the increasingly used endoscopic endonasal approach (EEA) requires further study. A growing body of research has demonstrated that frailty is a greater predictor of poor outcomes than advanced age. Methods: A retrospective review of NFPAs in patients ≥ 65 years old and treated via EEA between 2007 and 2022 at a single tertiary academic medical center was performed. Clinical data were retrospectively obtained from the electronic medical record and radiographic review of each patient. Clinical and pathological data were collected along with two separate frailty scores, the modified frailty index (mFI-11) and the risk analysis index (RAI). Logistic regression analysis was performed to determine factors associated with gross total resection (GTR) rates and the factors associated with recurrence were assessed using Cox proportional hazards modeling. Results: A total of 217 consecutive EEAs in 211 elderly patients with NFPAs met the inclusion criteria. The median duration of postoperative radiographic follow-up was 27.1 months (IQR: 6.50–49.97). The median age was 72 years (range: 65–90), and 130 patients (61.6%) were male. 186 cases (86%) received primary treatment with EEA while 31 cases (14%) were treated for recurrent or residual NFPA. Thirty-three patients (15.6%) presented with apoplexy; 118 cases (55%) presented with subjective visual deficit, of which 77.1% improved postoperatively. 94/217 (43.3%) cases had pre and postoperative visual acuity data: 53 (56.4%) presented with a visual acuity deficit and postoperatively 39 (73.6%) improved, and 1 (1.9%) had worsened visual acuity. 92/217 (42.4%) cases had pre and postoperative visual field data: 61 (66.3%) presented with a visual field deficit and postoperatively 45 (73.8%) improved, while 2 (3.3%) had worsened visual fields. Among apoplexy patients, 5 patients (15.2%) had preoperative palsies of which four (80%) had postoperative complete improvement and one (25%) had partial improvement of palsies. Seven patients (3.2%) had a postoperative DVT/PE, seven patients (3.2%) had a postoperative cerebrospinal fluid leak, two patients had a postoperative vascular injury (0.9%), and two patients (0.9%) died shortly after surgery due to operative complications (one had an intraoperative ICA injury, and one had postoperative thalamic infarct). 154 cases had gross total resection (77%). Earlier year of surgery, prior radiotherapy, redo operations, and posterior cavernous invasion were negatively associated with GTR in a multivariate logistic regression model. Gross total resection was significantly associated with decreased recurrence, while growth hormone (GH) staining and redo operations were significantly associated with increased recurrence in multivariate Cox proportional-hazards regression. A logistic regression model for postoperative complications found no associations with age or frailty scores. Conclusion: Our experience suggests that the EEA for nonfunctional adenomas in elderly patients (> 65 years) is safe and effective. Elderly patients had high rates of visual recovery postoperatively and acceptable rates of GTR compared to the literature on nonelderly patients. Although risk factors for progression and subtotal resection exist, EEA provides a safe option for NFPA resection in elderly patients ([ Tables 1 ]–[ 3 ]). Table 1 Table 2 Table 3 Publication History Article published online: 05 February 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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