Surgically treated giant pituitary neuroendocrine tumors: systematic review and meta-analysis with institutional cohort.

INTRODUCTION: This study aims to compare endoscopic endonasal approaches (EEAs) and transcranial approaches (TCAs) for the surgical treatment of giant pituitary neuroendocrine tumors (GPitNETs). METHODS: A systematic literature review was conducted using PubMed, Ovid MEDLINE, and Web of Science for studies on GPitNETs treated with EEA or TCA up to April 2025, following PRISMA guidelines. Meta-analysis was performed using random effects to estimate pooled event rates and heterogeneity. Risk of bias was assessed with the ROBINS-I tool. Additionally, a retrospective cohort of 20 patients was included, for a total of 1,052 patients across 21 studies. Seven studies were comparative. RESULTS: A total of 21 studies (2010–2024) met inclusion criteria, with 1,032 patients undergoing EEAs or TCAs for GPitNETs. Additionally, we included a retrospective cohort of 20 patients from our institution, for a total sample of 1,052. Meta-analysis was conducted on 7 comparative studies with a total of 273 patients. Visual improvement was significantly higher with EEA (OR 3.73; 95% CI: 1.44–9.64; p < 0.01). Gross total resection (GTR), progression rates and most postoperative complications, including cerebrospinal fluid (CSF) leak, infection, diabetes insipidus, and hypopituitarism (HP), showed no significant differences. However, intracranial hemorrhage (ICH) was more frequent with TCAs (OR 0.09; 95% CI: 0.02–0.45; p < 0.01). Study heterogeneity ranged from low to moderate depending on the endpoint. CONCLUSIONS: Endoscopic endonasal approaches provide better visual outcomes and lower ICH risk in GPitNETs. No statistically significant differences were observed between EEAs and TCAs in terms of GTR, progressive rates, or postoperative complications, including CSF leak, infection, diabetes insipidus, and HP.