Partial or full preservation of the pituitary stalk in craniopharyngioma surgery: improving endocrinological outcomes without an increased risk of recurrence.

Abstract

The risk-benefit balance of pituitary stalk (PS) preservation during craniopharyngioma (CP) surgery remains insufficiently investigated. Although preservation requires meticulous microsurgical dissection, frequent invasion of the PS by the CP also raises the question of the feasibility of preservation. Herein, the authors assessed the impact of preserving the PS in a large consecutive series of adult patients who underwent endoscopic endonasal surgery for CP. The authors performed a retrospective single-center study of adult, surgery-naive patients with supradiaphragmatic CP treated via the extended transsphenoidal transtubercular approach between 2002 and 2023. The following variables were analyzed: PS status (fully preserved, partially preserved, and sacrificed or not identified), extent of CP resection (gross-total, near-total, or partial resection), CP size, postoperative endocrine outcomes, recurrence, and use of adjuvant radiotherapy. Eighty-three patients were included in the study. The PS was fully preserved in 18% of patients, partially preserved in 17%, and sacrificed or not identified in 65%. PS preservation, either partially or fully, was associated with significantly lower rates of anterior pituitary deficiencies (p < 0.001), vasopressin deficiency (p = 0.001), and significantly lower postoperative weight gain (p = 0.033). When the maximal tumor diameter exceeded 24 mm, the risk of PS sacrifice increased threefold (p = 0.027). Partial or complete preservation of the PS during surgery for CP is associated with improved postoperative endocrine outcomes without compromising the tumor resection or increasing the risk of recurrence. When anatomically feasible, PS preservation should be considered as a key surgical objective in the management of CP.