Surgical outcomes of endoscopic endonasal surgery for nonfunctioning pituitary adenoma in elderly patients: a comprehensive analysis beyond age

Due to the rapid aging of the global population, it is challenging to identify elderly individuals who are optimal candidates for the surgical treatment of pituitary neuroendocrine tumors. While chronological age has traditionally influenced surgical decision-making, the independent effect of age on outcomes requires a comprehensive evaluation that controls for comorbidities and tumor characteristics. This retrospective analysis included 305 patients (≥18 years) who underwent endoscopic endonasal surgery for clinically nonfunctioning pituitary neuroendocrine tumors between March 2020 and February 2024 at a single tertiary center. Patients were stratified by age (<65 vs. ≥65 years) and evaluated using propensity score matching. The outcomes included gross total resection rates, complications, endocrinological recovery, and visual outcomes. Composite outcome measures were developed to assess multifaceted surgical success. Maximally selected rank statistics identified optimal age cutoffs for hormone recovery. The cohort included 305 patients. Elderly patients (≥65 years, n=105) presented with significantly greater comorbidity burdens, including hypertension and diabetes. Following propensity score matching (n=105 per group), no significant age-based differences were observed in terms of gross total resection rates (84.8% vs. 84.8%) or major complications. Age 57 was found to be the optimal cutoff for endocrinological recovery (60.7% vs. 33.1%, p<0.001), with the gonadotroph axis being the most significantly affected hormone axis. The visual outcomes demonstrated remarkable age independence, as recovery was mainly dependent on gross total resection and preoperative visual field severity. Multivariate analysis demonstrated that higher body mass index (BMI), specific cardiovascular comorbidities, and intraoperative cerebrospinal fluid leaks, rather than chronological age, served as independent predictors of adverse outcomes, including surgical site infections and prolonged hospital stays. Chronological age alone should not constitute an absolute contraindication to endoscopic pituitary surgery. These findings underscore that comprehensive preoperative evaluations should prioritize functional status and modifiable risk factors, including cardiovascular comorbidities and BMI, to optimize outcomes for patients of all ages.