Twenty years of neurosurgical experience with Cushing's disease: surgical strategies, endocrine outcomes, and remission predictors in 346 patients.

OBJECTIVE

Transsphenoidal surgery is the first-line treatment for Cushing's disease (CD), but long-term remission rates and predictors of outcome vary. This study analyzes 20 years of neurosurgical experience, including surgical strategies, endocrine outcomes, and remission predictors.

METHODS

Between 2004 and 2024, 346 patients with confirmed CD underwent 376 pituitary surgeries at the University Hospital of Tübingen. Data on demographics, tumor imaging, surgical technique, remission, recurrence rates, postoperative complications, and improvement of comorbidities were analyzed.

RESULTS

Early remission was achieved in 81.9% at discharge and 89.8% at first follow-up. During long-term follow-up (mean 109.7 months), a recurrence rate of 9.4% occurred. Primary surgery achieved higher remission rates than repeat surgery (94.1% vs 70.5% at first follow-up; 86.1% vs 57.4% long-term, both P < .001). Preoperative predictors included detectable microadenoma on magnetic resonance imaging (MRI) (P = .001) and smaller adenoma size (mean 7.5 mm vs 12.6 mm, P = .001). Invasive adenoma growth on MRI correlated with lower remission rates. Intraoperative factors associated with remission included shorter surgical duration (82.1 vs 101.3 min, P < .001), clear adenoma visualization (P < .001), histopathological confirmation (P = .003), use of selective adenomectomy (P < .001), and absence of intraoperative invasiveness (P = .003). Remission correlated with greater improvement in hypertension (P < .001), diabetes mellitus type 2 (P = .030), and weight loss (P < .001), while new pituitary hormone deficiencies occurred mainly after extensive surgery.

CONCLUSION

Transsphenoidal surgery remains an effective and safe treatment for CD, with high remission rates and long-term control, strongly associated with tumor characteristics and surgical approach.