This study compared the perception of nasal obstruction, quality of life, and costs of endoscopic vs. microscopic transsphenoidal pituitary surgery in an otolaryngology reference center in Colombia, a low/middle-income country. Overall, surgical-related costs were higher in the endoscopic group, which is different from two prior studies in United States that stated that the endoscopic approach is more cost effective19,20. However, we stand out that we found a difference in the median operating time of 0.67 hours favoring the microscopic approach, which may influence in the surgery-related costs for each intervention. A prior meta-analysis by Gao et al reported no significant differences in the length of the operation between both approaches: 173 ± 5 minutes for the endoscopic group vs. 201 ± 46 minutes for the microscopic group (P = 0.349)1. However, no statistically significant differences were found, and this variable could be affected by the type of tumor and the surgeon's expertise. No significant differences were found regarding the surgical bleeding between both surgical approaches. In terms of the postoperative hospital stay, these findings are consistent with prior meta-analyses1,2. We highlight that the sample size is a major limitation of this study, and the results should be interpreted considering this scenario.
The most frequent postoperative complications for both surgical interventions in our population were: postoperative cerebrospinal fluid leak (4.08%) and surgically induced hypopituitarism (2.04%). Likewise, prior meta-analyses reported that the most common postoperative complications include cerebrospinal fluid leak (7–15%) and surgically induced hypopituitarism (22%)1,2. Thus, our results are comparable to previous findings. However, we stand out that no case of hypercortisolism was found in the population treated with the microscopic approach. Prior authors reported a higher occurrence of complications in microscopic operations (27%) compared to endoscopic approaches (17%)6. These differences could be explained by the fact that the microscopic approach is highly influenced by the surgeon’s expertise.
In terms of nasal obstruction, a median difference of 45 points was found in the global scores of the NOSE scale between the microscopic and endoscopic approaches, favoring the microscopic approach. Conversely, prior studies reported that fewer post-operative nasal symptoms (i.e., anosmia, septal perforation, epistaxis) were found in the endoscopic compared to microscopic approaches21–23. These differences could be related to differences in the time assessments of this outcome as some studies assess the nasal obstruction in immediate postoperative stages. Osborne et al reported that among 136 European patients the post-operative nasal symptoms transiently worsen in both approaches but ultimately improve compared to the pre-operative baseline24. Moreover, the heterogeneity of the tools used to assess nasal outcomes could also lead to different findings in the few papers that have directly compared these groups. Therefore, we also applied a VAS to assess the nasal obstruction in the study population. A median difference of 4 points was found in the VAS score (p < 0.001 in both comparisons), also favoring the microscopic approach. Moreover, we found a strong linear correlation between VAS and NOSE. Therefore, our findings in the NOSE and VAS scores were consistent in our population.
Both approaches were conducted using a transeptal approach; thus, we argue that these differences may be related to the use of a nasoseptal flap in the endoscopic approach. Similarly, Hong et al reported better Anterior Skull Base Nasal Inventory outcomes at one and three months after surgery for the microscopic approach, especially for “nasal crusting” and “urge to blow nose”11. Moreover, Alobid et al reported that the use of a vascularized septal flap led to worse sinonasal symptoms in patients undergoing endoscopic transsphenoidal surgery25. Worse olfactory outcomes and mucociliary clearance in patients in which a vascularized septal flap have also been reported, which may be due to the re-epithelialization of the exposed cartilage and bone that in a prolonged duration of healing26,27.
Regarding the quality-of-life outcomes, the GBI median scores were 27.78 points (IQR: 55.56) for the microscopic approach and 25.00 (IQR: 25) for the endoscopic technique. In a multicenter study including 301 European patients, Little et al assessed the effect of the transsphenoidal technique using both endoscopic and microscopic approaches on the quality of life of these patients using the EuroQol-5D-5L instrument12. This study reported that surgical technique did not show significant variations in these patient-reported measures when performed at high-volume centers. Our findings were consistent with these results. However, we highlight that in the GBI domains, a significant difference was found in the “Physical health” item, favoring the microscopic approach. This finding could be related to the previously described nasal symptoms. We stand out that A negative correlation between the GBI and NOSE scales was found (ρ ̂=-0.44; 95% CI: -0.684 to -0.095), which means that the less postoperative nasal obstruction, the better quality of life. This scenario highlights the impact of sinonasal outcomes in patients’ quality of life and stands out that there’s a quality-of-life advantage in terms of nasal obstruction favoring the microscopic approach in our population. Finally, beyond the statistical differences, we highlight that these findings are clinically relevant, since the patients reported significant nasal differences favoring the microscopic approach.
Among the study limitations, we highlight the recall bias due to the ambispective collection of information. Furthermore, the source of information was partially based on medical records; therefore, missing data were found in two patients, which corresponds to 4.08% of the total sample. Also, the quality of results and conclusions depends on the quality of the medical records as mentioned in studies based on these types of sources28–31. Finally, it was not possible to measure non-anatomical and anatomical factors that could be associated with the perception of nasal obstructive symptoms such as allergic rhinitis or abnormalities in the nasal valve. Therefore, the results should be analyzed considering this scenario.