INTRODUCTION — Transsphenoidal surgery is the mainstay of treatment for most kinds of pituitary adenomas and other sellar masses. This topic review covers the techniques, results, and complications of transsphenoidal surgery of pituitary adenomas and other sellar masses. The endocrine evaluation of these disorders, as well as options for medical therapy of prolactinomas and acromegaly, are reviewed elsewhere. (See "Causes, presentation, and evaluation of sellar masses" and "Pituitary incidentalomas" and "Management of hyperprolactinemia" and "Treatment of acromegaly".)
ANESTHETIC CONCERNS — Anesthetic concerns for patients who undergo transsphenoidal surgery are most significant for patients who have secretory lesions (ie, patients with acromegaly and Cushing disease). In addition, patients with hormonal deficiencies (eg, hypothyroidism) should be identified and, if necessary, treated preoperatively. (See 'Perioperative management' below.)
Airway management may be difficult in patients with acromegaly and Cushing disease because of anatomic distortion. Similar to patients without acromegaly, airway evaluation using the usual metrics (eg, Mallampati classification, mouth opening, neck range of motion, thyromental distance) may be falsely reassuring in patients with acromegaly (table 1 and table 2 and table 3 and table 4) . Equipment and personnel for difficult airway management should be immediately available during induction of anesthesia for these patients. Awake intubation may be the best option in severely affected patients. (See "Management of the difficult airway for general anesthesia in adults".)
For acromegalic patients with severe airway compromise, it may be advisable to pre-treat the patient with a somatostatin analog or growth hormone receptor antagonist for a few months prior to planned surgery, in an attempt to minimize airway edema and facilitate safe intubation. Those acromegalic patients with significant cardiomyopathy may also benefit from pre-treatment in an attempt to improve cardiac function before undergoing transsphenoidal surgery. (See 'Somatotroph adenomas (acromegaly)' below.)
Patients with acromegaly and Cushing disease are at increased risk of hypertension and cardiovascular disease, obstructive sleep apnea, diabetes, and other manifestations that may affect anesthetic care. (See "Epidemiology and clinical manifestations of Cushing syndrome", section on 'Frequency and severity of symptoms' and "Causes and clinical manifestations of acromegaly", section on 'Clinical manifestations'.)
Anesthesia for transsphenoidal pituitary surgery is discussed separately. (See "Anesthesia for transsphenoidal pituitary surgery".)
SURGICAL TECHNIQUES — Transsphenoidal surgery is relatively noninvasive as it utilizes the nasal passages and sinus anatomy to reach the sella. Successful resection requires that the surgeon:
●Navigate to the sella
●Visualize the tumor through a relatively narrow corridor
●Remove the tumor as completely as possible
●Minimize damage to the surrounding structures, including the normal pituitary gland
Navigation — Precise navigation to the sella is critical because it is bounded by the carotid arteries and optic nerves and chiasm; two techniques are in common use:
●Intraoperative fluoroscopy, which gives real-time localization relative to bony anatomy, though only in the two-dimensional sagittal plane
●Neuronavigation devices, which provide computed localization referenced to a three-dimensional (3D) space calculated from preoperative imaging
Approach — Three transsphenoidal approaches are commonly used today:
●Posterior nasopharynx – The most common approach to the sphenoid is directly through the posterior nasopharynx, with an incision at the sphenoid ostia or posterior septum . This approach is constrained by the size of the nasal passage, but gives direct access to the sphenoid and can be used with both endoscopic and microscopic techniques.
●Sublabial – The sublabial approach employs an incision through the upper gum to reach the nasal aperture and then approaches submucosally along the septum to the sphenoid. While this approach provides wide access, it requires a painful incision, and the submucosal tunnel necessitates postoperative nasal packing.
●Nasal aperture – A mucosal incision can be made at the anterior nasal aperture, directly raising a submucosal tunnel and approaching posteriorly along the septum; this avoids the sublabial incision, but access is somewhat more limited by the diameter of the nasal passage, and postoperative packing may be required .
●Extended transsphenoidal approach – The introduction of improved endoscopic techniques has allowed the development of the "extended transsphenoidal" approach, where a portion of the tuberculum sella is removed extending up from the sella. This permits resection of suprasellar tumors with intracranial extension but carries a greater risk of cerebrospinal fluid (CSF) leakage and intracranial complications .
Visualization — The introduction of the operative microscope to pituitary surgery by Hardy in the early 1960s allowed the removal of microadenomas and revolutionized the surgical treatment of pituitary disease .
Operating microscope — The operating microscope provides superb optics with binocular vision, but visualization is constrained to line of sight along a relatively narrow corridor.
Endoscope — Based upon advances made in sinus surgery, the endoscope was introduced to transsphenoidal surgery in the early 1990s . It allows a wider field of view, which is useful in large tumors. The operative field is visualized on a high-definition screen. Because most endoscopes are monocular, the surgeon loses binocular vision and depth perception, although 3D endoscopes are under development. It has become increasingly popular over time and is employed at many major centers.
Resection and repair — Most tumor resection can be done with a combination of transsphenoidal curettes and suction. The extent of the resection depends on the consistency of the tumor, which may vary considerably, from very soft to very fibrous. Softer tumors will be easier to resect more completely and easier to separate from the normal gland, allowing its preservation. Fibrous tumors are more difficult to resect and to dissect from the normal pituitary, increasing the chance that the normal pituitary will be damaged, resulting in postoperative hormone deficiencies. The adenoma can sometimes be excised intact (movie 1). After tumor removal, the sella is usually reconstructed with subcutaneous abdominal fat, muscle, or artificial hemostatic material, especially in cases of intraoperative CSF leakage. With extensive skull base resection, a vascularized or free mucosal graft can be used to repair the defect.
Determination of the extent of resection — Determining the extent of tumor resection may be difficult but is aided by:
●Indirect cues, eg, prolapse of the diaphragm sella into the surgical field, which suggests adequate decompression of the chiasm.
●Endoscopy, which may allow visualization at angles not possible to be seen directly.
●Intraoperative magnetic resonance imaging (iMRI). This requires the construction of a shielded operating room at significant cost, with workflow altered by the presence of a strong magnetic field. Studies report variable rates (5 to 60 percent) of additional adenoma resection by using this technique [7-13], but the results can be difficult to interpret because the studies employ different magnet strengths (0.5 to 3.0 T), vary in size of the adenomas resected (micro to macro), and the timing of the initial images are at the surgeon's discretion (imaging earlier in the course of surgery will inflate the utility of the technique). In a meta-analysis of 85 studies, the gross total resection rate for an iMRI-assisted microscopic approach was approximately the same as the endoscopic approach for large macroadenomas, suggesting that these techniques may be complementary .
Risks of surgery — Risks of surgery include hormonal deficiencies and damage to parasellar structures, as well as general surgical risks. All complications occur less frequently with more experienced surgeons and institutions.
Experience of the surgeon — When surgery has been chosen as the best treatment for a patient with a sellar mass, we recommend that the patient be referred to an experienced surgeon. Two studies illustrate the importance of the pituitary surgeon's experience:
●In a survey of 958 neurosurgeons, those who reported performing a total of more than 500 transsphenoidal procedures reported fewer serious and less serious complications than a neurosurgeon who had performed fewer than 200 (table 5) .
●In a study using the Nationwide Inpatient Sample 1996 to 2000, neurosurgeons who performed more procedures had fewer complications than those who performed fewer surgical procedures .
Hormonal deficiencies — The rate of new postoperative hormonal deficiencies ranged from 7 to 20 percent in one large survey . In a meta-analysis, the incidence of new postoperative hormone insufficiency was 5 to 10 percent for prolactinomas, growth-hormone secreting adenomas, and nonfunctioning tumors but was considerably higher (25 percent) for patients with Cushing disease; this may be due to the need for long-term steroid replacement, or to the more extensive dissection within the gland .
The risk of hormone insufficiency also varies with the size and consistency of the adenoma, the extent of resection, and the experience of the surgeon . Deficiencies result from damage to, or excision of, the anterior pituitary or the stalk. The latter causes arginine vasopressin deficiency (AVP-D), which occurs transiently in approximately 10 to 20 percent of surgeries but permanently in only 2 to 7 percent [15,18].
Damage to parasellar structures — Potential damage to parasellar structures as a result of surgery include:
●CSF rhinorrhea – This occurs in 0.5 to 4 percent of reported cases . If lumbar subarachnoid diversion is unsuccessful in allowing the leak to heal, reoperation for repacking of the adenoma bed is required. Failure to stop the leak risks meningitis.
●Damage to an internal carotid artery – This damage results from operating too far from the midline and can result in massive, sometimes fatal, hemorrhage.
●Damage to the optic chiasm or optic nerves – This can result from direct damage but more commonly results from postoperative hemorrhage into residual adenoma causing compression of the suprasellar chiasm.
●Surgical mortality – The complications listed above are serious and can lead to death. In the United States, surgical mortality is estimated to be approximately 0.8 percent , perhaps <0.2 percent in more experienced centers .
Comparison of microscopic versus endoscopic techniques — Comparison of the two techniques is limited because few studies are prospective or randomized. Comparison therefore is based upon reviews and meta-analyses of studies of the individual techniques.
Several meta-analyses have shown no clear difference between the two techniques in complete removal of the adenoma [19-23]. In one meta-analysis of 37 studies that included over 5500 patients, there were no significant differences in rates of gross total resection or hormone-excess remission . Overall complication rates, including CSF leak, syndrome of inappropriate antidiuretic hormone secretion (SIADH), visual improvement or loss, epistaxis, or meningitis, were similar for the two techniques, but the endoscopic approach was associated with a lower rate of septal perforation, AVP-D, and hypothyroidism . The endoscopic approach may also result in decreased operating time, length of hospital stay, nasal complications, and pain and discomfort [20-22]. Of note, the control group in some of the older studies was the more invasive sublabial approach.
In Cushing disease, a meta-analysis of 97 studies showed similar remission rates (approximately 80 percent) in microadenomas for both endoscopic and microscopic approaches, with a trend towards improved remission in macroadenomas with the endoscopic approach .
The studies included in most meta-analyses, however, are retrospective and are neither randomized nor controlled. Direct comparison of extent of resection by endoscopic versus microscopic surgeons at individual institutions have shown similar rates of resection [25,26], but the endoscopic technique may prove more successful with larger tumors  and is becoming the predominant technique at many centers .
Another meta-analysis reported no significant difference in several complications between the two techniques, with the exception of increased risk of vascular complications with endoscopic procedures .
Perioperative management — We recommend evaluation of pituitary function in patients with sellar masses before and after transsphenoidal surgery. Prior to surgery, the evaluation should focus on determining the presence of hormonal hypersecretion, in order to identify, if possible, if the mass is a secretory adenoma. The evaluation should also determine if any hormonal deficiencies exist.
Hypothyroidism should be treated before surgery because of the increased anesthetic risk of narcotics and barbiturates in the hypothyroid patient (see "Nonthyroid surgery in the patient with thyroid disease", section on 'Hypothyroidism'). Acromegalic patients with obvious predictors of difficulty with airway management during anesthesia or with cardiomyopathy may require treatment with a somatostatin analog or growth hormone receptor antagonist for several months prior to surgery. (See 'Anesthetic concerns' above.)
Management during and immediately after surgery involves the evaluation and treatment of:
●Cortisol deficiency – During and immediately after surgery, some experts routinely treat with glucocorticoids until normal adrenal function is demonstrated, but others wait until postoperative evaluation has demonstrated cortisol deficiency to treat. (See "Treatment of gonadotroph and other clinically nonfunctioning adenomas", section on 'Postoperative issues'.)
●AVP-D and the SIADH – Following transsphenoidal surgery, patients may exhibit AVP-D followed by SIADH followed by AVP-D, which may be transient or permanent. Some patients have all three phases, and others have only AVP-D or only SIADH. For this reason, fluid intake and output, serum sodium, and urine osmolality should be measured at least once a day for a few days after surgery. If no abnormalities are found, sequential sodium levels should be obtained for one to two weeks after surgery to determine if SIADH has occurred. (See "Treatment of gonadotroph and other clinically nonfunctioning adenomas", section on 'Postoperative issues'.)
●Emerging data suggest that postoperative mild fluid restriction may decrease the risk of SIADH [29-31].
●CSF rhinorrhea – Patients should be monitored for postoperative CSF leakage by observing for clear nasal drainage. If a CSF leak is suspected, the fluid should be tested for beta transferrin (tau protein).
RESULTS BY TUMOR TYPE
Lactotroph adenomas — Because dopamine agonists are effective in lowering prolactin and decreasing adenoma size in approximately 90 percent of lactotroph adenomas, we recommend them as initial treatment even when the adenomas are very large and cause visual and other neurologic effects (see "Management of hyperprolactinemia"). However, we recommend surgery in the following situations [32,33] (see "Management of hyperprolactinemia", section on 'Role of transsphenoidal surgery'):
●Dopamine agonists are ineffective in lowering prolactin or relieving neurologic deficits, or
●Dopamine agonists cause intolerable side effects
In addition, we consider surgery in the following situations:
●A patient prefers surgery to long-term dopamine agonist treatment
●A patient with a lactotroph macroadenoma wishes to become pregnant, to attempt to avoid dopamine agonist treatment during pregnancy 
In a series from the dopamine agonist era, surgical treatment overall (including giant invasive tumors) normalized prolactin levels in 53.2 percent of cases. In selected subgroups, however, surgery was much more effective: 72.5 percent remission in intrasellar tumors, 80 percent in cystic prolactinomas, and 84.8 percent in microprolactinomas. The overall recurrence rate was 18.7 percent, although only 7.1 percent in microadenomas . One review suggested that transsphenoidal surgery for microprolactinomas may remain a reasonable option in some cases, with an approximate 83 percent remission rate after surgery .
Somatotroph adenomas (acromegaly) — For patients who have a somatotroph adenoma that is entirely or mostly confined to the sella or a larger adenoma that is impairing vision, we recommend transsphenoidal surgery as initial treatment. Transsphenoidal surgery offers the potential for rapid cure of acromegaly. The chance of cure depends on the size and invasiveness of the adenoma and the experience of the surgeon. Cure is defined by clinical remission and normalization of the age-adjusted insulin-like growth factor-1 (IGF-1) and/or the glucose-suppressed growth hormone (GH) to <1.0 ng/mL. Because of its long half-life, IGF-1 often does not reach its nadir after surgery for more than a month and sometimes for several months  (see "Treatment of acromegaly", section on 'Transsphenoidal surgery'). Updated clinical practice guidelines for the management of acromegaly have been published [37-41].
The chance of cure using the endoscopic approach in five series of 24 to 60 patients each was approximately 80 to 90 percent for microadenomas and 50 to 60 percent for macroadenomas [42-47]. An earlier report using the microscopic approach in 57 patients reported similar results . A report in which endoscopic (71 patients) and microscopic (41 patients) approaches were compared at one institution, but by two different experienced surgeons, showed similar results with the two approaches (87 percent microadenoma remission, 66 percent macroadenoma remission, greater nasal complications with endoscopy) . All of these reports were from centers where one or two surgeons perform large numbers of procedures.
The cure rate is lower, however, when surgery is performed at institutions where it is performed less often. For example, in a report of 1344 patients with all sizes of adenomas at 42 centers in the German Acromegaly Registry, the cure rate was 38.8 percent . Centers that performed more surgeries had better rates than those that performed fewer.
Because the surgical remission rate is lower when the adenoma is larger and invasive, treatment algorithms have been developed using medical treatment with somatostatin analogues (SSAs) as primary therapy . However, the overall remission rate (GH <2.5 ng/mL and normal IGF-1) for primary medical treatment with SSAs in unselected patient groups (ie, unselected for responsiveness to SSAs) appears to be only 20 to 25 percent in medically naïve patients [51,52], and response to SSAs is a function of pretreatment GH levels . This author therefore recommends debulking surgery in many patients where surgical cure cannot be achieved, although primary medical treatment in some of these cases is a reasonable option.
Surgical debulking should definitely be considered in the following situations (see "Treatment of acromegaly", section on 'Transsphenoidal surgery'):
●There is visual impairment, as surgery offers a much better chance of restoring vision quickly than a somatostatin analog.
●Primary medical treatment has failed, as surgical debulking appears to increase the responsiveness of somatotroph adenomas to medical treatment [54,55].
Pretreatment of somatotroph adenomas with an SSA has been proposed to reduce the size of the adenoma and thereby increase the chance of complete removal, but the results are unclear. Although randomized, prospective trials have shown an increased cure rate with pretreatment, interpretation is uncertain because the cure rates in the untreated patient groups were much lower than typical by historical standards [56-58]. Another possible benefit of pretreatment with an SSA is improvement in the medical comorbidities that increase anesthetic risk . (See 'Anesthetic concerns' above.)
●In one meta-analysis, recurrence rates for acromegaly after apparent initial cure were approximately 5 percent at six years of follow-up .
Corticotroph adenomas — For patients who have corticotroph micro- or macroadenomas, we recommend transsphenoidal surgery as initial treatment. Prior to contemplating surgery, however, the diagnosis of Cushing disease must be firmly established by demonstration of corticotropin (ACTH)-dependent hypercortisolemia and clear evidence that the pituitary is the source of the ACTH. (See "Establishing the cause of Cushing syndrome".)
Glucocorticoid coverage — If surgery is successful, the serum cortisol falls dramatically by the first or second postoperative day, although some patients have delayed remissions from several days to several months . Practice varies as how to balance the need for assessing adrenal status and treating the severe adrenal insufficiency that occurs if surgery has been successful . (See "Primary therapy of Cushing disease: Transsphenoidal surgery and pituitary irradiation".) :
●Some experts do not administer exogenous glucocorticoids during and after surgery; instead, they measure serum cortisol at 8 AM the next morning and administer a glucocorticoid only if the patient has signs and symptoms of adrenal insufficiency and/or very low serum cortisol. This approach is best utilized when patients are monitored postoperatively in the hospital for sign of adrenal insufficiency, which may require an extended length of stay to complete this assessment.
●At the author's institution, patients are usually discharged on the first postoperative day. We therefore begin low-dose dexamethasone (0.5 mg daily) while concurrently measuring fasting serum and 24-hour urinary free cortisol levels as an outpatient, beginning on postoperative day 1. The low-dose dexamethasone will prevent the development of severe adrenal insufficiency, but allow an early determination of potential remission to be made, as it does not cross-react with the cortisol assay, nor does it suppress the hypothalamic-pituitary-adrenal axis. After adequate testing has been performed, the patient is transitioned to hydrocortisone or prednisone replacement until the adrenal axis has recovered. (See "Anesthesia for transsphenoidal pituitary surgery", section on 'Perioperative glucocorticoids'.)
If surgery has been successful, glucocorticoid replacement, in gradually decreasing doses, may be required for up to a year afterwards.
Outcomes — Success of initial surgery depends on the size of the adenoma. In one report, the success rate for 72 microadenomas was 94.5 percent and, for 11 macroadenomas, 64.0 percent . In another report, the success rate for 103 microadenomas was 72.8 percent and, for 21 macroadenomas, 42.9 percent . In two other reports that did not distinguish between micro- and macroadenomas, the success rates were 82.7 percent  and 72.0 percent . In a meta-analysis of 5787 patients in 50 papers over a 30-year period, the overall success rate was 71.3 percent .
In the author's experience, success also depends on whether or not the adenoma can be visualized by magnetic resonance imaging (MRI). Those visualized offer the best surgical results, but remission is often achieved even if not. In the absence of visualization by MRI, confirmation of a pituitary source of ACTH by inferior petrosal sinus catheterization is mandatory.
●Persistent disease – When surgery has been unsuccessful, and even a delayed remission excluded, additional treatment is needed. One option is repeat surgery. Most surgeons, including the author of this topic, favor re-exploration within a few weeks, because postoperative scarring later makes re-exploration more difficult. Early pituitary re-exploration has been reported to achieve remission in an additional 50 to 70 percent of patients, although the incidence of hypoadrenalism is greater [65,66].
Some endocrinologists consider other treatments when initial surgery is unsuccessful, including total adrenalectomy, pituitary radiation, and pharmacologic treatment, based upon on the patients' individual circumstances. . (See "Primary therapy of Cushing disease: Transsphenoidal surgery and pituitary irradiation".)
●Recurrent disease – Even when initial surgery appears to have been successful, there may be a very small amount of residual adenoma tissue that grows and eventually results in recurrent cortisol excess. Estimates of recurrence rate in the literature vary from 3 to 25 percent at five years but appear to average at approximately 10 percent [17,67-69]. The risk of recurrence depends on:
•The size of the adenoma – The chance of recurrence is more common in macro- than microadenomas.
•Criteria used to determine success of surgery – More stringent initial remission criteria may be associated with lower recurrence rates , although this is not completely clear, and even patients with initially undetectable postoperative cortisol levels may later have a recurrence . There is a higher rate of recurrence in patients whose postoperative cortisol levels are normal , as opposed to subnormal, and in those patients whose initial remission was delayed .
•Duration of follow-up – Most recurrences occur within five years after surgery, but some occur up to 10 years later and rarely thereafter.
A recurrence must be treated, and reoperation is one option. Success of reoperation is approximately 40 to 60 percent, but even some of those apparently successful will recur again [70,71]. One cause of persistent recurrence is thought to be invasion of adenoma cells into the dura, which is technically difficult to resect. Dural invasion has been estimated to occur in approximately 34 percent of cases based on dural biopsies . (See "Primary therapy of Cushing disease: Transsphenoidal surgery and pituitary irradiation".)
Transsphenoidal surgery for Cushing disease in children is technically more challenging than that in adults [73,74]. Remission rates are comparable with those in adults, but some studies have found a higher risk of recurrence .
Gonadotroph and other clinically nonfunctioning adenomas — For gonadotroph and other clinically nonfunctioning macroadenomas that are impairing vision, we recommend transsphenoidal surgery as it is the only effective treatment. Success rates are a function of adenoma size and invasiveness. Gross total resection can be achieved in approximately 60 percent of macroadenomas, less often if the adenoma has extensively invaded the cavernous sinus. Following surgery, visual field defects improve in 60 to 80 percent of patients [76,77]. Also following surgery, pituitary hypofunction may improve in as many as 30 percent , as well as worsen. (See 'Risks of surgery' above.)
Surgery should also be considered in patients with macroadenomas approaching the chiasm without visual symptoms, or those with progressive enlargement on serial imaging. (See "Treatment of gonadotroph and other clinically nonfunctioning adenomas", section on 'Initial therapy: Transsphenoidal surgery'.)
Nonpituitary sellar lesions — Although the majority of sellar lesions are pituitary adenomas, many other lesions occur in this area and often cannot be distinguished from a pituitary adenoma by MRI. These are sometimes not recognized as nonpituitary lesions until pathologic examination of the excised tissue . (See "Causes, presentation, and evaluation of sellar masses".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diagnosis and treatment of Cushing syndrome" and "Society guideline links: Diagnosis and treatment of acromegaly" and "Society guideline links: Pituitary tumors and hypopituitarism".)
SUMMARY AND RECOMMENDATIONS
●Transsphenoidal surgery – Transsphenoidal surgery is the preferred treatment for most kinds of pituitary adenomas. The diagnostic evaluation, indications for surgery, and options for medical therapy for each type of pituitary adenoma are reviewed separately. (See "Management of hyperprolactinemia" and "Treatment of acromegaly" and "Treatment of gonadotroph and other clinically nonfunctioning adenomas" and "Overview of the treatment of Cushing syndrome".)
Visualization – Some pituitary neurosurgeons use an operating microscope, and others use an endoscope; use of the endoscope has become increasingly common. The risk of serious side effects, including visual loss, hemorrhage, and meningitis, are quite low and similar using both techniques. The risks of pituitary hormonal deficiencies are also similar using the two techniques, as is the likelihood of complete removal of the adenoma in most cases, although endoscopy may be more effective in very large tumors. Experienced surgeons have greater success in removing the adenoma completely and a lower incidence of complications.
●Surgeon experience – When surgery has been chosen as the best treatment for a patient with a pituitary adenoma, the patient should be referred to a surgeon who specializes in pituitary surgery and has extensive experience in either the microscopic or endoscopic approach. (See 'Experience of the surgeon' above.)
●Anesthesia – Anesthetic concerns for patients who undergo transsphenoidal surgery are most significant for patients who have secretory lesions (ie, patients with acromegaly and Cushing disease). Airway management during anesthesia may be unexpectedly difficult, and these patients may have comorbidities that affect anesthetic management. (See 'Anesthetic concerns' above.)
●Hormonal evaluation – We perform a hormonal evaluation before surgery to determine the presence of a secretory adenoma and also to determine if hormonal deficiencies exist that may require preoperative replacement. We then re-evaluate hormonal function after surgery to determine if hypersecretion by the adenoma has been corrected and if hormonal function of the normal gland has improved or worsened. (See 'Perioperative management' above.)
•Dopamine agonists – For patients who have lactotroph adenomas, no matter how large, we recommend a dopamine agonist, such as cabergoline, as initial treatment in most cases. (See "Management of hyperprolactinemia", section on 'Overview of dopamine agonists' and 'Lactotroph adenomas' above.)
•Patients with macroadenomas – For patients who have lactotroph macroadenomas that impair vision and either do not respond or have intolerable side effects to cabergoline, we perform transsphenoidal surgery. A woman with a large macroprolactinoma may wish to consider surgery before pregnancy because of the risk that it will increase to a clinically important size before delivery, or that it may require ongoing dopamine agonist treatment during the pregnancy. (See "Management of lactotroph adenoma (prolactinoma) before and during pregnancy", section on 'Transsphenoidal surgery to decrease adenoma size' and 'Lactotroph adenomas' above.)
●Acromegaly – For patients who have a somatotroph adenoma that is entirely or mostly confined to the sella or a larger adenoma that is impairing vision, we recommend transsphenoidal surgery as initial treatment. We also suggest consideration of surgery for a somatotroph adenoma even if it is thought not to be entirely resectable, in order to improve the growth hormone (GH) response to pharmacologic treatment. (See "Treatment of acromegaly", section on 'Transsphenoidal surgery' and 'Somatotroph adenomas (acromegaly)' above.)
●Corticotroph adenomas – For patients who have corticotroph micro- or macroadenomas, we recommend transsphenoidal surgery as the initial treatment. If the initial surgery is not successful, we favor re-exploration within a few weeks because postoperative scarring later makes re-exploration more difficult. Early pituitary re-exploration has been reported to achieve remission in an additional 50 to 70 percent of patients, although the incidence of hypoadrenalism is greater. Other treatment options for persistent or recurrent disease include total adrenalectomy, pituitary radiation, and pharmacologic treatment. (See "Primary therapy of Cushing disease: Transsphenoidal surgery and pituitary irradiation" and 'Corticotroph adenomas' above.)
●Gonadotroph adenomas – For gonadotroph and other clinically nonfunctioning macroadenomas that are impairing vision, we recommend transsphenoidal surgery. Surgery should also be considered in patients with macroadenomas approaching the chiasm without visual symptoms, or those with progressive enlargement on serial imaging. (See 'Gonadotroph and other clinically nonfunctioning adenomas' above and "Treatment of gonadotroph and other clinically nonfunctioning adenomas", section on 'Initial therapy: Transsphenoidal surgery'.)
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