Continuous white-light/indocyanine green overlay endoscopy in pituitary adenoma surgery: A prospective feasibility and safety study.

INTRODUCTION

Intraoperative differentiation between pituitary adenoma (PA) and normal gland tissue remains a key challenge in endoscopic transsphenoidal surgery (ETSS). Indocyanine green fluorescence (ICG-FL) has been proposed as a visual adjunct. Existing data are limited and primarily based on first-generation systems requiring intermittent mode switching.

RESEARCH QUESTION: Is implementation of a second-generation ICG endoscope with continuous white-light/near-infrared (WL/NIR) overlay safe and feasible in routine PA surgery?

MATERIALS AND

METHODS

This prospective single-center observational study included consecutive patients undergoing ETSS for PA over a 28-month period. A second-generation ICG-FL endoscope with continuous WL/NIR overlay visualization was used throughout tumor resection. Primary endpoints were adverse events related to ICG-administration or device use. Secondary endpoints included surgical complications, short-term endocrine outcome and radiological residual tumor.

RESULTS

After screening, 130 patients met inclusion criteria. Continuous WL/NIR overlay was successfully applied in all cases without intraoperative technical failure, dye-related adverse events, or need to revert to white-light-only visualization. Among functional PAs, 75% (52/69) achieved early biochemical remission. At follow-up, 22 patients (17%) had radiologically confirmed residual tumor, while 73 (56%) showed no residual disease. When combined with functional cases not undergoing MRI due to confirmed remission (n = 27), extrapolated gross-total resection was 77%.

DISCUSSION AND

CONCLUSIONS

Continuous ICG-FL guidance was safe and feasible in routine ETSS for PA, without compromising surgical workflow, anatomical visualization, or requiring conversion to white-light-only endoscopy. Complication rates were consistent with contemporary endoscopic series. Continuous fluorescence provides real-time perfusion information that may facilitate improved tissue differentiation and warrants further comparative evaluation.