National Trends in the Surgical Management of Functioning and Non-Functioning Pituitary Adenomas: A 14-Year Analysis

Background: Clinical equipoise persists in the management of pituitary adenomas. Current evidence is limited to Class III studies, with no high-level data demonstrating the superiority of surgery over medical or observational management. When surgery is pursued, recent guidelines from the Congress of Neurological Surgeons (CNS) highlight insufficient evidence to definitively recommend endoscopic over microscopic techniques for functioning adenomas. An analysis of national practice trends is therefore critical for benchmarking the current standard of care and identifying key shifts in treatment paradigms. This study leverages a large-scale database to characterize contemporary surgical management patterns and address these evidence gaps. Methods: This retrospective cohort study leveraged de-identified data from the TriNetX Research Network, a global EHR-based platform. We identified patients diagnosed with pituitary adenomas from 2011-2024 and analyzed trends in management strategies—observation, medical therapy, surgery, and radiation—for the overall cohort. The cohort was then stratified into functioning adenomas (FA) vs. non-functioning adenomas (NFA). Surgical approaches were sub-categorized as transsphenoidal vs. craniotomy, with transsphenoidal procedures further classified as endoscopic or microscopic. Temporal trends for each group were quantified using the Joinpoint Regression Program to detect significant inflection points in practice patterns. We also examined demographics, comorbidities, and clinical features across all treatment and surgical subgroups. Results: Analysis of 127,013 patients treated for pituitary adenomas between 2011-2024 was performed. Results revealed observation as the predominant and increasing management strategy (mean 61.7%; APC +3.6%, P