Optimizing Surgical Approaches for Complex-Giant Pituitary Adenomas: A Tertiary Center Analysis of 49 Cases in the Past Years

Giant pituitary adenomas (GPAs) pose significant surgical challenges due totheir large size, parasellar/suprasellar extensions, and proximity to criticalneurovascular structures. Although the endoscopic endonasal approach (EEA) ispreferred for pituitary tumors, achieving gross total resection (GTR) in GPAsremains difficult. Additional transcranial approaches may improve resectionrates while minimizing morbidity. This study evaluates the impact of endoscopicand combined surgical approaches on resection outcomes using a classificationsystem previously defined in GPA patients treated over the past year.MethodsAmong 517 pituitary adenomas treated in our clinic between September 2023and September 2024, 49 GPA patients underwent endoscopic endonasal,transcranial, or combined surgery. Data included demographics, symptoms,imaging, surgical details, and follow-up outcomes. Tumor resection rates wereanalyzed based on the “landmark-based classification,” considering radiologicaland pathological features and surgical approach.ResultsThe mean age was 45.5 years (female/male: 14/35). Zone distribution was 8 (Zone1), 21 (Zone 2), and 20 (Zone 3). GTR was achieved in 34.6%, near-total resection in36.7%, and subtotal resection in 28.5%. Endoscopic surgery was performed in 41patients, combined surgery in 7, and a transcranial approach in 1. Complicationsincluded diabetes insipidus (9/49), cerebrospinal fluid leakage (2/49), apoplexy(2/49), hypocortisolism (3/49), epidural hematoma (1/49), and epistaxis (1/49).ConclusionsWhile EEA is effective for Zone 1 and 2 GPAs, Zone 3 tumors often requirecombined or transcranial approaches for better resection. A multimodal strategyoptimizes tumor removal while minimizing morbidity. Individualized surgicalplanning based on tumor classification is crucial for improving outcomes.