Transsphenoidal Approach for Pituitary Adenomas in the Elderly: Meta-analysis of Safety and Surgical Efficacy

Objective: Pituitary adenomas (PA) in the elderly (≥65 years old) represent 5% of all adenomas, and due to an aging population, this proportion is likely to increase. Transsphenoidal surgery (TSS) is a treatment mainstay for these lesions; however, safety and efficacy of TSS in the elderly is controversial. Here, we perform a safety and efficacy meta-analysis of TSS for PAs in the elderly.

Methods: A literature search of PubMed and Google Scholars databases was performed to capture pertinent English-language studies from 1995 to 2019 discussing efficacy (extent of resection; recurrence) and safety (complication; mortality) of TSS in patients ≥65 years. Search terms included combinations of “transsphenoidal” and “elderly” (e.g., [“transsphenoidal surgery” AND “elderly”], so forth). Data extraction was performed by two authors (S.S.S. and J.C.).

Results: Twenty-six papers describing 1,264 elderly patients undergoing TSS for PAs were identified, six of which included 1,610 non-elderly (<65 years) control patients undergoing similar treatment. Average age (72.7 ± 4.2 vs. 39.5 ± 9.9 years, p < 0.0001), male gender (62 vs. 41%, p < 0.0001), and American Society of Anesthesiology preoperative scores (p < 0.001) were significantly higher in the elderly group versus control group. Nonfunctional PAs were the most common tumor type in both groups (63 and 55%). Average length of stay was similar between elderly and non-elderly cohorts (6.2 vs. 6.0 days). Comparison between surgically treated elderly and non-elderly patients revealed no difference in rates of gross total resection (59 vs. 71%, p = 0.22), recurrence (8.4 vs. 20.1%, p = 0.054), intraoperative complications (1.1 vs. 1.3%, p = 0.35; mainly intraoperative CSF leak), serious postoperative complication (4.5 vs. 6.0%, p = 0.62), or disease-related mortality at follow-up (0.4 vs. 0.2%, p = 0.64). However, the rates of intraoperative CSF leak were lower in the elderly cohort (OR: 0.4, 95% CI: 0.26–0.67, p < 0.01). As expected, all-cause mortality was higher in the elderly group (OR: 4.22, 95% CI: 1.28–13.9, p = 0.01).

Conclusion: Elderly patients are not subject to higher rates of overall complications than the non-elderly cohort. Lower rates of intraoperative CSF leak were seen in the elderly population; we hypothesize that this decreased risk of intraoperative CSF leak in the elderly is related to more conservative resection strategies in an attempt to avoid complications. The results of this meta-analysis indicate that age should not be a sole contraindication to TSS.