Pituitary Stalk Sacrifice does not Improve Oncological Outcomes in Adult Craniopharyngioma

Introduction: Craniopharyngiomas arising from embryological remnants of Rathke’s pouch frequently encase or invade the infundibulum, creating a surgical dilemma: preserve the stalk to maintain hypothalamic-pituitary connectivity or sacrifice the stalk to maximize extent of resection and reduce recurrence risk. We evaluated whether graded infundibular sacrifice (preserved, partial, complete) improves tumor control at the expense of predictable endocrine morbidity in a homogeneous cohort of adults undergoing primary craniopharyngioma resection. Methods: This is a single-institution retrospective cohort study of consecutive adult patients who underwent endoscopic endonasal approach (EEA) for resection of newly diagnosed craniopharyngioma from 2008 to 2024. Primary outcomes included tumor recurrence and new endocrine deficits (diabetes insipidus (DI), panhypopituitarism). Statistical analyses were performed using R. Univariate comparisons employed chi-square tests, ANOVA, Kruskal-Wallis, and t -tests as appropriate to identify potential confounders associated with both stalk management and outcomes. Variables demonstrating associations were subsequently included in multivariable logistic regression (for binary recurrence) adjusting for gross total resection (GTR) status, tumor volume, and infundibular location to isolate the independent effect of stalk management on oncological outcomes. Results: We identified 55 adults undergoing EEA for primary craniopharyngioma resection. Of these 55 patients, 31 (56.4%) were male and the average age was 52.8 ± 16.5. 29 (52.7%) underwent GTR, and 17 (30.9%) had recurrence ( Table 1 ). Intraoperative infundibulum management was stratified into: preserved (12, 21.8%), partially resected (24, 43.6%), or sacrificed (19, 34.5%). Univariate analysis revealed significant associations between tumor volume and recurrence (p=.01), non-GTR and recurrence ( p = 0.04), and stalk sacrifice and new onset panhypopituitarism ( p = 0.0004). Notably, GTR and new panhypopituitarism ( p = 0.486), GTR and new diabetes insipidus (DI; p = 0.698), and stalk sacrifice and recurrence ( p = 0.965) were all not significantly associated. GTR and stalk sacrifice ( p = 0.213) and stalk sacrifice and new DI ( p = 0.197) had minor but insignificant associations. Following multivariate analysis, only non-GTR was significantly associated with recurrence ( p = 0.006) while only stalk sacrifice was significantly associated with new panhypopituitarism ( p < 0.001). Conclusion: This study shows that GTR is the single factor that may decrease the rate of recurrence in patients with craniopharyngioma without necessarily causing panhypopituitarism. Our findings suggest that stalk preservation should be a potential goal of craniopharyngioma surgery as stalk sacrifice universally causes panhypopituitarism without significant oncologic benefit. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany