Craniopharyngioma resection by endoscopic endonasal approach versus transcranial approach: A systematic review and meta-analysis of comparative studies

Abstract

IntroductionThe transcranial approach (TCA) has historically been used to remove craniopharyngiomas. Although the extended endoscopic endonasal approach (EEA) to these tumors has been more commonly accepted in the recent two decades, there is debate over whether this approach leads to better outcomes. The goal of this systematic review and meta-analysis was to more comprehensively understand the benefits and limitations of these two approaches in craniopharyngioma resection based on comparative studies.MethodsWe conducted a systematic literature search in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations using MEDLINE, EMBASE, and the Cochrane Library. A total of 448 articles were screened. Data were extracted and analyzed using proportional meta-analysis. Eight comparative studies satisfied the inclusion criteria. The extent of resection, visual outcomes, and postoperative complications such as endocrine dysfunction and cerebrospinal fluid (CSF) leakage were compared.Results and discussionEight studies, involving 376 patients, were included. Resection by EEA led to a greater rate of gross total resection (GTR) (odds ratio [OR], 2.42; p = 0.02; seven studies) with an incidence of 61.3% vs. 50.5% and a higher likelihood of visual improvement (OR, 3.22; p < 0.0001; six studies). However, TCA resulted in a higher likelihood of visual deterioration (OR, 3.68; p = 0.002; seven studies), and was related, though not significantly, to panhypopituitarism (OR, 1.39; p = 0.34; eight studies) and diabetes insipidus (OR, 1.14; p = 0.58; seven studies). Although TCA showed significantly lower likelihoods of CSF leakage (OR, 0.26; 95% confidence interval [CI], 0.10–0.71; p = 0.008; eight studies) compared to EEA, there was no significant difference in meningitis (OR, 0.92; 95% CI, 0.20–4.25; p = 0.91; six studies) between the two approaches. When both approaches can completely resect the tumor, EEA outperforms TCA in terms of GTR rate and visual outcomes, with favorable results in complications other than CSF leakage, such as panhypopituitarism and diabetes insipidus. Although knowledge of and competence in traditional microsurgery and endoscopic surgery are essential in surgical decision-making for craniopharyngioma treatment, when both approaches are feasible, EEA is associated with favorable surgical outcomes.Systematic review registrationhttp://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021234801.

Endoscopic Endonasal Approach for Residual and Recurrent Craniopharyngioma after Transcranial Approach: A Multi-institutional Experience

“…8 Multiple retrospective studies and reviews have similarly reported variable nonzero rates of visual or endocrinologic deficits after EEA. 13,17 Here we report stable or improved outcomes in terms of visual deficits and hormone replacement needs in 13 patients, describing a comparable cohort of patients undergoing EEA following TCA for CP who had no postoperative worsening of visual deficits or hormone replacement needs.…”

Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach

“…On the other hand, Komotar et al reported a recurrence rate after TCA in 28.20% ( p < 0.001) [ 5 ]. Many studies saw this trend for higher recurrence rates in the TCA [ 4 ]. A possible explanation for the worse outcomes in TCA could be inherent to the tumor characteristics and some undisclosed factors that influenced the decision to use TCA over EEA; however, the increased visual symptoms, headache, and hypopituitarism pre-surgery would hint that the tumors resected by EEA were just as challenging.…”

“…A recent meta-analysis showed better visual and endocrine outcomes (including panhypopituitarism and diabetes insipidus) for the EEA compared to TCA. Moreover, these results show an interesting tendency that favors EEA [ 4 ]; however, this study included only studies that directly compared the techniques, limiting the number of articles to eight and including 370 patients. Additionally, previous reviews, such as the one published by Komotar et al in 2012, which included a higher number of studies, showed that the differences were minor [ 5 ].…”

Microsurgical Resection of Suprasellar Craniopharyngioma by Pterional Approach: 3-Dimensional Operative Video

“…In addition, transcranial approaches have a much lower likelihood of cerebrospinal fluid (CSF) leakage compared to EEA. 3a-6a…”

“…In a recent meta-analysis, EEA for craniopharyngiomas showed a higher likelihood of visual improvement, gross total resection and similar rates of panhypopituitarism compared to transcranial approaches. 3a Conversely, some studies report similar extent of resection between transcranial and EEA approaches, suggesting that patient selection and experience with endoscopic techniques may play a role in these outcomes. 7a With regards to patient selection, 1 of the historic limitations of EEA was extension of the tumor intraventricularly.…”