Twenty years of neurosurgical experience with Cushing’s disease: surgical-strategies, endocrine outcomes and remission predictors in 346 patients

OBJECTIVE: Transsphenoidal surgery (TSS) is the first-line treatment for Cushing's disease (CD), but long-term remission rates and predictors of outcome vary. This study analyses 20 years of neurosurgical experience, including surgical strategies, endocrine outcomes, and remission predictors. METHODS: Between 2004 and 2024, 346 patients with confirmed CD underwent 376 pituitary surgeries at the University Hospital of Tübingen. Data on demographics, tumor imaging, surgical technique, remission, recurrence rates, postoperative complications and improvement of co-morbidities were analysed. RESULTS: Early remission was achieved in 81.9% at discharge and 89.8% at first follow-up. During long-term follow-up (mean 109.7months) a recurrence rate of 9.4% occurred. Primary surgery achieved higher remission rates than repeat surgery (94.1% vs. 70.5% at first follow-up; 86.1% vs. 57.4% long-term, both p < 0.001). Preoperative predictors included detectable microadenoma on MRI (p = 0.001) and smaller adenoma size (mean 7.5 mm vs. 12.6 mm, p = 0.001). Invasive adenoma growth on MRI correlated with lower remission rates. Intraoperative factors associated with remission included shorter surgical duration (82.1 vs. 101.3 min, p < 0.001), clear adenoma visualization (p < 0.001), histopathological confirmation (p = 0.003), use of selective adenomectomy (p < 0.001), and absence of intraoperative invasiveness (p = 0.003). Remission correlated with greater improvement in hypertension (p < 0.001), diabetes mellitus type 2 (p = 0.030), and weight loss (p < 0.001), while new pituitary hormone deficiencies occurred mainly after extensive surgery. CONCLUSION: TSS remains an effective and safe treatment for CD, with high remission rates and long-term control, strongly associated with tumor characteristics and surgical approach.