Endoscopic Versus Microscopic Transsphenoidal Surgery in the Treatment of Pituitary Adenoma: A Systematic Review

Pituitary adenomas are the most prevalent pituitary pathology and originate from the neoplastic proliferation of anterior pituitary lobe cell lineages. Two primary surgical approaches are employed: microscopic transsphenoidal surgery (MTS) and endoscopic transsphenoidal surgery (ETS). Both approaches aim to optimize tumor resection while reducing the risk of complications. The objective of this review is to compare the outcomes of ETS and MTS in the treatment of pituitary adenomas. Studies from 1974 to March 20, 2026, from PubMed, ScienceDirect, and Cochrane databases were included. The inclusion criteria were patients diagnosed with pituitary adenomas and patients aged ≥18 years. The systematic review includes a total of 22 articles with a total of 4390 participants, of which 2413 underwent ETS and 1973 underwent MTS. The findings suggest that gross total resection (GTR) was more frequently reported in patients undergoing the endoscopic technique; however, considerable variability exists across studies. Postoperative complication rates were variable and showed substantial overlap between endoscopic and microscopic techniques. Although the endoscopic technique may provide some benefits, overall safety and recovery outcomes seem to be affected more by study features and the surgeon's experience than by the surgical method itself. The comparison between both surgical techniques suggests potential advantages for the endoscopic approach in terms of GTR; however, clinical outcomes, including complications, recovery, and endocrine function, are comparable between techniques and appear to be influenced more by surgical expertise, tumor characteristics, and study design than by the surgical approach alone.