Clinical and Surgical Outcomes of Pediatric Cushing's Disease Following Endoscopic Transsphenoidal Surgery

Clinical and Surgical Outcomes of Pediatric Cushing's Disease Following Endoscopic Transsphenoidal Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical and Surgical Outcomes of Pediatric Cushing's Disease Following Endoscopic Transsphenoidal Surgery Guive Sharifi, Elham Paraandavaji, Mohammad Mehdi Mousavi Nasab, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4937982/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Mar, 2025 Read the published version in Child's Nervous System → Version 1 posted 9 You are reading this latest preprint version Abstract Background Cushing's disease (CD) is characterized by hypercortisolism due to excessive adrenocorticotropic hormone (ACTH) secretion from a pituitary adenoma. Though more common in adults, pediatric cases constitute approximately 5% of those seen in adults. Early diagnosis and treatment are critical due to the severe impacts on growth and development in children. Endoscopic transsphenoidal surgery (ETSS) is the preferred first-line treatment for both children and adults. Methods From 2011 to 2024, 3,280 patients with pituitary adenoma underwent surgery using the ETSS technique at Loghman Hospital of Tehran, including 213 CD cases, of which 22 were pediatric (under 18 years old). This retrospective study analyzed clinical data such as age, gender, presenting symptoms, family and medical history, imaging characteristics, surgical findings, pathology, follow-up, and postoperative outcomes. Diagnostic criteria included biochemical tests, MRI imaging, and inferior petrosal sinus sampling. Results Out of 22 pediatric patients, 16 were females and 6 males, with an average age of 14.73 years. Obesity was the initial clinical manifestation in 59% of the patients. According to the Hardy-Wilson classification, 18.2% of patients were stage E, 9.09% stage C, and the rest (excluding MRI-negative patients) stage A. ETSS was performed on all patients, with total hypophysectomy in 18.2% and hemi-hypophysectomy in 9.09%. Postoperative complications included cerebrospinal fluid leakage in 13.63% of patients. Remission was achieved in 95.45% of patients, with a recurrence rate of 4.54%. Hormone imbalances post-surgery included hypocortisolism (50%), hypothyroidism (45.45%), and hypogonadism (13.63%). Conclusion ETSS is an effective and safe treatment for pediatric CD, achieving high remission rates and minimal complications. This study highlights the importance of specialized surgical care in managing pediatric CD and underscores the need for early diagnosis and intervention. Further studies are warranted to evaluate long-term outcomes and optimize treatment protocols. Cushing's disease Pediatric endocrinology Endoscopic transsphenoidal surgery Pituitary adenoma Hypercortisolism Surgical outcomes Figures Figure 1 Introduction Cushing's disease (CD) is a pathological state characterized by hypercortisolism, occurring when a pituitary adenoma secretes an excessive amount of adrenocorticotropic hormone (ACTH). Hypercortisolemia, marked by elevated cortisol secretion, is attributed to the presence of a pituitary corticotrophic adenoma. While predominantly reported in adults, this phenomenon can also occur in children, albeit rarely [ 1 , 2 ]. The occurrence of CD in children is estimated to be around 5% of that observed in adults [ 3 ]. CD accounts for 70% of cases of adult-onset endogenous Cushing’s syndromes and 75–80% of cases of pediatric-onset endogenous Cushing’s syndromes [ 2 , 4 – 6 ]. It is associated with severe illness in both pediatric and adult patients; hence, early diagnosis and treatment are crucial for optimal therapeutic outcomes [ 7 ]. Pituitary radiotherapy and transsphenoidal pituitary surgery are considered the most effective therapeutic options for these patients. The clinical presentations of hypercortisolemia can exhibit substantial variation across all age groups, frequently complicating the establishment of a precise diagnosis. Moreover, the initial symptoms of pediatric CD may be underestimated and differ from those observed in adult patients [ 7 – 9 ]. Typical observations in pediatric CD include growth retardation with weight gain, a higher occurrence in males, and abnormal puberty [ 10 – 12 ]. Although there are documented differences in the onset of CD in adults and children, the diagnostic criteria and investigation methodologies for pediatric cases are typically derived from established practices for adults. The primary goal of treating CD is to quickly normalize cortisol levels, especially in children, due to the adverse effects of prolonged high cortisol levels on growth and development [ 7 ]. Endoscopic Transsphenoidal Surgery (ETSS) is the recommended first-line treatment for both children and adults with CD, involving the targeted surgical removal of the adenoma. ETSS in children presents technical challenges and requires specialized care from a highly trained pediatric neurosurgeon [ 8 , 13 ]. Consistently undetectable serum cortisol levels (less than 50 nmol/l) within a week post-surgery are regarded as the most reliable indicator of successful treatment for CD [ 8 ]. The primary aim of this study is to evaluate the clinical and surgical outcomes in pediatric patients with CD, a rare condition with limited prior investigations. Materials and methods From 2011 to 2024, a total of 3,280 patients with pituitary adenoma underwent surgery using the ETSS technique at Loghman Hospital of Tehran. Among these patients, 213 were diagnosed with CD, and 22 were pediatric cases with age not exceeding 18-years-old (Fig. 1 ). A retrospective investigation was conducted on 22 consecutive pediatric patients with CD who underwent transsphenoidal microsurgery. The clinical data collected included age, gender, presenting symptoms, family and medical history, imaging characteristics, operative findings such as Hardy-Wilson classification and adenoma size, pathology results, follow-up, and postoperative outcomes, including diabetes insipidus, complications, and current endocrine status. The Hardy-Wilson classification assessed the level of damage to the sellar region (grade) and the extent of expansion beyond the sellar region (stage) [ 1 ]. Extrasellar extension, according to the Hardy-Wilson modified scale, is categorized into different stages: Stage 0 indicates no suprasellar extension, Stages A-C represent progressive suprasellar extension (A indicates occupation of the cistern, B indicates destruction of the recess of the third ventricle, and C indicates gross displacement of the third ventricle), and Stages D-E represent parasellar extension (D indicates intracranial extension and E indicates cavernous sinus extension). All patients provided written informed consent before enrolment. Institutional review board approval was waived as deidentified information of patients was retrospectively collected. Diagnostic Evaluation: A multidisciplinary panel comprising members from the Departments of Endocrinology, Neurosurgery, Radiology, and Pathology established the diagnosis of CD. The diagnosis was confirmed through biochemical tests, including urine free cortisol (UFC), daytime serum ACTH, and low-dose and high-dose dexamethasone suppression tests (LDSST and HDDST). The diagnostic criteria included tumor detection via contrast-enhanced MRI or dynamic gadolinium-enhanced MRI, sustained hypercortisolism confirmed by morning and evening plasma cortisol levels, 24-hour UFC levels, LDDST, HDDST, or contrast-enhanced MRI, along with positive results from inferior petrosal sinus sampling (IPSS) to rule out the presence of a tumor. If no tumors were identified or if there were suspicions, IPSS was performed according to the protocol described by Feng [ 5 ]. Operation and Post-operation All ETSS operations were performed by the same surgical team supervised by the senior author (G.Sh). The surgical techniques and informed consent were discussed, considering the patient's age, history, and disease severity. Upon the discovery of an adenoma during surgery, expanded adenomectomy (removal of both the adenoma and the surrounding pituitary tissue) was performed. Postoperative clinical and endocrinological evaluations were conducted within 7 days after surgery to assess remission and within 6 months after surgery to determine residual disease. Patients were classified as being in remission if they exhibited clinical adrenal insufficiency and had serum cortisol levels below 2.5 µg/dL at 48 hours after surgery or below 1.8 µg/dL with a low-dose dexamethasone suppression test in the third month postoperative. Additionally, they needed to show a restoration of their circadian rhythm, improvement in symptoms, and no evidence of an adenoma in MR imaging. Persistent illness was characterized by higher postoperative cortisol levels and a requirement for further CD therapy within a 6-month period. Additionally, gadolinium-enhanced and/or dynamic gadolinium-enhanced MRI of the pituitary gland was employed to validate the reappearance of the condition [ 6 , 7 ]. Results Out of the 22 patients, 16 were young females and 6 were young males, with an average age of 14.73 years (range 11–17). Obesity was the initial clinical manifestation in 59% of the patients, while menstrual problems and striae were reported in 18.2% of the patients. None of the patients had a family history of MEN Syndrome, but 4.54% had a family history of CD. Regarding their medical history, 22.72% had a history of fatty liver, 13.63% had dyslipidemia, 9.09% had diabetes mellitus, and 4.54% were in a pre-diabetic state. Detailed demographic and medical history information is provided in Table 1 . Table 1 Patient Demographic and Clinical Characteristics Patient ID Age Gender Duration of Symptoms (months) First Manifestation Family History of Pituitary Adenoma Family History of MEN Past Medical History X 1 17 Male 18 Obesity (28 Kg) No No No X 2 15 Female 12 Menstural disorder No No No X 3 16 Female 15 Menstural disorder No No Fat Liver, Dyslipidemia X 4 11 Female 24 Obesity (12 Kg) No No No X 5 15 Female 6 Obesity (12 Kg) No No No X 6 12 Female 50 Obesity (30 Kg) No No HTN, Fat Liver X 7 14 Female 36 Striae Yes (her cousin) No Fat Liver X 8 15 Female 9 Obesity (30 Kg) No No No X 9 14 Male 12 Obesity (12 Kg) No No No X 10 17 Female 24 Headache No No No X 11 14 Female 12 Menstural disorder No No HTN, Fat Liver, Dyslipidemia X 12 17 Male 6 Obesity (30 Kg) No No No X 13 16 Female 2 Striae No No No X 14 16 Male 18 Obesity (13 Kg) No No HTN X 15 15 Female 12 Obesity (24 Kg) No No HTN, DM X 16 15 Male 24 Blurred vision No No No X 17 14 Female 24 Obesity (30 Kg) No No Fat Liver, Dyslipidemia X 18 17 Female 12 Striae No No DM X 19 12 Female 3 Obesity (15 Kg) No No No X 20 14 Female 12 Obesity (15 Kg) No No No X 21 16 Female 48 Menstural disorder No No Pre DM X 22 12 Male 24 Obesity (28 Kg) No No No TOTAL (11–17) Female: % (16/22) Male: % (6/22) Mean 18.3 Blurred vision: (1/21) Obesity: (13/22) Menstural disorder: (4/22) Striae: (3/22) Headache: (1/21) Family History of Pituitary Adenoma: % (1/22) FH MEN: 0% (0/22) HTN: (4/22) DM: (2/22) Pre DM: (1/22) Fat Liver: (5/22) Dyslipidemia: (3/22) According to the Hardy-Wilson classification, 18.2% of patients were classified as stage E, 9.09% as stage C, and the rest (excluding MRI-negative patients) as stage A. Additionally, 18.2% of patients exhibited invasion into the cavernous sinus, and 9.09% showed evidence of hemorrhagic sella on their imaging. All patients underwent ETSS surgical treatment (Table 2 and Fig. 1 ). Among them, 18.2% also underwent total hypophysectomy, and 9.09% underwent hemi-hypophysectomy. Radiation therapy was performed in 9.09% of patients, with one patient eligible for bilateral adrenalectomy. No surgical complications developed except for cerebrospinal fluid (CSF) leakage, which was observed in 13.63% of patients. Further details on the surgical treatments are provided in Table 2 . Table 2 Surgical and Treatment Details Patient ID Size of Adenoma Multifocality Invasion Hardy-Wilson Classification Additional Findings Number of surgeries Surgical Approach Resection X 1 Micro Unifocal No 1A 1 ETSS Adenomectomy X 2 Micro Multifocal No 1A 1 ETSS Adenomectomy X 3 Macro Unifocal Cavernous Sinus Knosb 2 First Op: 3E 2nd Op: 3E 2 ( Same surgeon) ETSS Adenomectomy X 4 Micro Unifocal No 1A 1 ETSS Adenomectomy X 5 Micro Unifocal No 1A Hemorrhagic 1 ETSS Adenomectomy X 6 Micro Unifocal No 1A 1 ETSS Adenomectomy X 7 2nd Op: Micro Unifocal Cavernous Sinus Knosb 1 2nd Op: 1E 2 (Other surgeon) ETSS Adenomectomy X 8 Micro Unifocal No 1A 1 ETSS Hemi-hypophysectomy X 9 MRI Neg. - No 0 1 ETSS Adenomectomy X 10 Macro Unifocal No 1A 1 ETSS Adenomectomy X 11 Micro Unifocal No 1A 1 ETSS Adenomectomy X 12 MRI Neg. - No 0 1 ETSS Adenomectomy X 13 Micro Unifocal No 1A 1 ETSS Total-hypophysectomy X 14 Macro Unifocal Cavernous Sinus Knosb 1 2E Empty sella, Hemorragic 1 ETSS Adenomectomy X 15 Micro Unifocal No 1A 1 ETSS Hemi-hypophysectomy X 16 Macro Multifocal No 2C 1 ETSS Total-hypophysectomy, Stalkectomy X 17 First Op: Micro 2nd Op: MRI Neg. First Op: Multifocal 2nd Op: 0 First Op: Cavernous Sinus Knosb 1 First Op:2E 2nd Op: 0 2 ( Same surgeon) ETSS Adenomectomy X 18 2nd Op: Micro Unifocal No 2nd Op : 1A 2 (Other surgeon) ETSS Adenomectomy X 19 Macro Multifocal No 2C 1 ETSS Total-hypophysectomy, Stalkectomy X 20 Micro Unifocal No 1A 1 ETSS Total-hypophysectomy X 21 Micro Unifocal No 1A 1 ETSS Adenomectomy X 22 2nd Op: Micro Unifocal No 2nd Op : 1A 2 (Other surgeon) ETSS Adenomectomy TOTAL Last Op; Micro: (14/22) Macro: (5/22) MRI Neg: (3/22) Last Op; Unifocal: % (16/22) Multifocal: % (3/22) Last Op; Cavernous Sinus Invasion: Knosb 1: % (2/22) Knosb 2: % (1/22) Last Op; 1A: % (14/22) 2C: % (2/22) 1E: % (1/22) 2E: % (1/22) 3E: % (1/22) Hemorrhagic Tumor: % (2/22) Empty Sella: % (1/22) 1 Op : % (17/22) 2 Op: % (5/22) ETSS: 100% (22/22) Last Op: Adenomectomy: % (16/22) Hemihypophysectomy: % (2/22) Total Hypophysectomy: % (4/22) Stalkectomy : % (2/22) Overall, 95.45% of patients went into remission, while the rest did not respond to the surgical treatment. Additionally, 4.54% of patients experienced a recurrence of CD after achieving remission and required re-operation. Temporary diabetes insipidus occurred in 40.09% of patients. Most patients experienced hormone imbalances following surgery, with 50% experiencing hypocortisolism, 45.45% hypothyroidism, and 13.63% hypogonadism. Table 3 provides more details on surgical outcomes. Table 3 Postoperative Complications & Outcomes Patient ID Immediate Complications Additional Treatment Follow-up Period (months) Long-Term Complications Outcomes Post Op DI (No, Temporary, Permanent) Last Endocrine Status X 1 0 0 105 No Remission No NL X 2 0 0 102 HTN Remission No NL X 3 0 Radiotherapy, Bilateral Adrenalectomy 91 No Remission Temporary Hypocortisolism X 4 0 0 90 No Remission No Hypothyroidism, Hypocortisolism X 5 0 0 78 No Remission No Hypocortisolism X 6 0 0 78 Menstural disorder Remission Temporary Hypothyroidism, Hypocortisolism X 7 0 0 78 No Remission Temporary Hypogonadism X 8 0 0 66 No Remission Temporary NL X 9 CSF Leak 0 63 No Remission X 10 0 0 60.5 No Remission No NL X 11 0 0 54 Menstural disorder, Insulin Resistance, Dyslipidemia Remission No NL X 12 CSF Leak 0 51 No Remission No Hypothyroidism, Hypocortisolism X 13 Epistaxis 0 50 Infertility Remission No Hypothyroidism, Hypogonadism, Hypocortisolism X 14 0 0 45 HTN, Dyslipidemia, Depression Remission No NL X 15 CSF Leak 0 44 Menstural disorder Remission Temporary Hypothyroidism, Hypocortisolism X 16 0 Radiotherapy 36 No Remission Temporary Hypocortisolism X 17 Electrolyte Imbalance 0 22 Insulin Resistance Recurrence after Remission (after 2 years of Op) Temporary Hypothyroidism X 18 0 0 20.5 Osteopenia Remission No Hypothyroidism, Hypocortisolism X 19 0 0 18 No Remission Temporary Hypothyroidism, Hypocortisolism X 20 0 0 10 No Remission No NL X 21 0 0 6 No Remission Temporary Hypothyroidism, Hypogonadism, Hypocortisolism X 22 0 0 6 No No Response No Hypothyroidism TOTAL CSF Leak: % (3/22) Epistaxis: % (1/22) Electrolyte Imbalance: % (1/22) Radiotherapy: % (2/22) Bilateral Adrenalectomy: % (1/22) 53.3 Months HTN : % (2/22) Dyslipidemia: % (2/22) Osteopenia: % (1/22) Insulin Resistance: % (2/22) Menstural disorder: % (3/22) Depression: % (1/22) Remission: % (19/22) No Response: % (1/22) Recurrence after Remission: % (1/22) DI No: % (13/22) Temporary: % (9/22) Hypocortisolism: % ( 11/22 ) Hypogonadism: % ( 3/22 ) Hypothyroidism: % ( 10/22 ) Discussion In the past, bilateral adrenalectomy was commonly used as the first-line treatment. While the method successfully reduced cortisol levels, there was still a danger of developing Nelson's syndrome after undertaking adrenalectomy for pituitary adenoma. Medical intervention aimed at reducing cortisol levels is a potential short-term treatment option, but it is not advisable as the primary therapy for Cushing's disease [ 1 ]. Transsphenoidal pituitary surgery is the preferred option for young patients with CD, as it allows for the targeted excision of the microadenoma [ 2 ]. Both transsphenoidal microscopic surgery (TSMS) and ETSS offer a safe and effective approach to accessing the sellar fossa, with a minimal incidence of complications and morbidity. The introduction of endoscope has led to significant advancements in transsphenoidal surgery. Currently, ETSS is the preferred procedure for pituitary surgery. We made the switch to ETSS in 2006 because it is less invasive than TSMS, while still achieving the same rates of full tumor removal. Additionally, patients who have ETSS have shorter hospital stays, both in adults and children [ 3 ]. The clinical manifestations of CD typically result from elevated cortisol production. The presentation exhibits significant variability. The diagnosis is often delayed due to the reason that growth failure may be the sole symptom for an extended period of time. Our series indicates that obesity and weight gain are the most common and initial symptoms of CD in pediatric patients. This finding is further supported by earlier research [ 4 , 5 ] Several elements of CD exhibit variations in the pediatric population. The frequency is greater in males than in females. Unlike prior works [ 6 ], our dataset exhibited an obvious female dominance, with females accounting for 72.72% of the total population compared to males at 23%. The significance of gender is evident in a study where it was shown that out of 102 pediatric patients, male participants had greater body mass index (BMI), potentially shorter height, and elevated plasma ACTH levels. This suggests that boys may have a more aggressive type of CD [ 7 ] In our study, 95.45% of patients experienced remission during the initial follow-up period and one patient experienced recurrence. One of our patients, who did not experience a successful recovery following their second surgery follow-up, was considered as a candidate for bilateral adrenalectomy. Out of these patients, 5 (22.72%) have previously undergone endoscopic operations, following the repeated ETSS procedure on these 5 patients, 4 of them successfully attained remission. There is a lack of evidence on the rates of remission of CD after undergoing repeat transsphenoidal surgery, with reported proportions varying between 28.9% and 73% [ 8 – 10 ]. The rates of recurrent CD after reoperation exhibit variability, with presented incidences ranging from 22–63.2% [ 11 , 12 ]. However, it is important to note that this data specifically pertains to adult patients with CD. Additionally, there is insufficient evidence about the rate of remission and recurrence after repeating ETSS in pediatric patients. Two patients had radiotherapy for the treatment of CD. Non-surgical alternatives, such as radiotherapy and radiosurgery, have been regarded useful for recurring or residual CD due to their low morbidity rates and appropriate remission rates [ 13 , 14 ]. However, for radiosurgery the remission rate varies across individuals. Therefore, it is important to acknowledge that ETSS provides much higher remission rate for microadenomas [ 15 ]. However, our research, similar to the study conducted by Hanalioglu et.al [ 16 ], indicates that the results and rates of complications related to repeated ETSS are similar to those of the initial ETSS for CD and better than alternative non-surgical treatments for persistent or recurring CD. Within our study, a total of 3 patients (13.63%) experienced rhinorrhea and required reoperation. This aligns with previously reported rates of CSF leakage, which typically ranges from 1 to 5%, after repeating endoscopic transsphenoidal surgery for residual or recurrent pituitary tumors [ 13 , 17 , 18 ]. Out of the patients we studied, 9 individuals (40.09%) had temporary diabetes insipidus (DI), Similarly, other studies have documented rates of DI ranging from 2 to 13% [ 13 , 17 ]. However, none of them acquired persistent DI. In addition, 50% of patients acquired hypocortisolism and 13.63% of patients had hypogonadism. While hypothyroidism developed in 45.45% of patients. According to a prior study, it is found that all four axis of preoperative pituitary deficit showed recovery, with an average recovery rate of 29.7%. The cortisol axis exhibited the most significant recovery, while the thyroid axis shown the least recovery, with cumulative recovery rates of 44.3% and 6.1% respectively, over the course of one year. Postoperative hypopituitarism was observed in 17.2% of cases, with the highest incidence in the thyroid axis (24.3%, 27 out of 111) and the lowest incidence in the cortisol axis (9.7%, 16 out of 165) [ 19 ]. Based on our results, 13.63% of our patients had negative MRI findings. However, all of these children obtained remission after undergoing surgery. In contrast, a study conducted by Tatsi et.al. [ 20 ] suggests that the remission rate in these MRI-negative patients is significantly lower compared to pediatric patients with positive MRI results. Also, it is important to note that empty sella is a condition commonly associated with pituitary adenomas especially somatotropic adenomas, as reported by Sharifi et al. [ 21 ] in their previous series. Strength and Limitation Our study is one of the largest case series in the existing literature that investigates the safety, feasibility, and effectiveness of ETSS for the management of recurring and diagnosed pediatric Cushing’s disease. The results of our study emphasize the safety and effectiveness of ETSS at specialized medical facilities, demonstrating high rates of successful treatment and minimal complication rates. Nevertheless, it is crucial to acknowledge the retrospective nature of our work, which automatically brings about potential biases such as selection bias. Our study specifically examines individuals who have undergone surgery for residual CD in pediatric. This limits our capacity to evaluate the effectiveness of surgical treatment with alternative methods like as radiation or radiosurgery. Conclusion This study highlights the effectiveness and safety of endoscopic transsphenoidal surgery in the management of Cushing's disease. Surprisingly, a significant proportion of patients (95.45%) experienced remission following their reoperation. In addition, the rates of complications observed in our study group were in line with the recorded rates for both initial and repeated transsphenoidal procedures. Endoscopic transsphenoidal surgery is a dependable and secure therapy method for Cushing's disease in pediatric patients, providing acceptable rates of remission along with minimal complications. Declarations Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Author Contribution G.SH ConceptualizationEP and MMMN writing the manuscriptEM Review editing NS and MRMT: investigationNAD: Supervision Acknowledgment Authors declare that they used OpenAI’s ChatGPT in a supervised manner only to revise the language and readability of current are very grateful for the patience and trust of our patients and their families. Also, we appreciate the hard works of our coworkers and other researchers. Availability of data All data used in this manuscript are available as deidentified material through direct request sent to corresponding author. References Savage MO, Dias RP, Chan LF, Afshar F, Plowman NP, Matson M et al (2010) Diagnosis and treatment of Cushing’s disease in children. Pediatr Neuroendocrinol 17:134–145 Guaraldi F, Storr HL, Ghizzoni L, Ghigo E, Savage MO (2014) Paediatric pituitary adenomas: a decade of change. 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Cite Share Download PDF Status: Published Journal Publication published 16 Mar, 2025 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Revision requested 05 Sep, 2024 Reviews received at journal 02 Sep, 2024 Reviews received at journal 30 Aug, 2024 Reviewers agreed at journal 24 Aug, 2024 Reviewers agreed at journal 21 Aug, 2024 Reviewers invited by journal 21 Aug, 2024 Editor assigned by journal 19 Aug, 2024 Submission checks completed at journal 19 Aug, 2024 First submitted to journal 19 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4937982","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":349919050,"identity":"985a8671-97a1-4422-8390-c7b883f8572f","order_by":0,"name":"Guive Sharifi","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Guive","middleName":"","lastName":"Sharifi","suffix":""},{"id":349919052,"identity":"9923b972-bca5-47fd-948a-ae22766faa73","order_by":1,"name":"Elham Paraandavaji","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elham","middleName":"","lastName":"Paraandavaji","suffix":""},{"id":349919054,"identity":"7694eab2-c281-4bcd-a7fd-1b8801995e0b","order_by":2,"name":"Mohammad Mehdi Mousavi Nasab","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Mehdi Mousavi","lastName":"Nasab","suffix":""},{"id":349919055,"identity":"1efdc997-8cf8-4d2a-b5c8-663f3eae9242","order_by":3,"name":"Esmaeil Mohammadi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIiWNgGAWjYNACAwsGBgkwi5mHH0QlFBDUIoHQItkA0mJA0BqEFgaDA2BDcKvl5z+d+OFDgUS0we3mp5tu1FjLGJ9fnfjhgQGDPL/YAaxaJGfkbpacYSCRu+HOMbPbOcfSecxuvN0sAXSY4czZCdh9cYN3gzQPSMuNBKAWtsNALWc3gLQkGNzGrsX+/NnNv/+AtaR/u53z7zCP8Yyzm3/g02LAkLtNmgGsJcfsdm7bYR4D/t5teG2RuJG7zbIHqGXmjZyy27l96TwSN3i3WSQYSOD0C3//2c03fvyxye27kb7tds43a3uQyM0fFTby/NLYtWCzGKxSgljlYIsPkKJ6FIyCUTAKRgAAAMMTZSXS9+YNAAAAAElFTkSuQmCC","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Esmaeil","middleName":"","lastName":"Mohammadi","suffix":""},{"id":349919056,"identity":"b2d3edbe-a689-4aad-a794-3b80b14dcf3b","order_by":4,"name":"Neginalsadat Sadeghi","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Neginalsadat","middleName":"","lastName":"Sadeghi","suffix":""},{"id":349919057,"identity":"3a60e3b4-80b0-4b0b-b064-ae360fcb6a1b","order_by":5,"name":"Mohammad Reza Mohajeri Tehrani","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Reza Mohajeri","lastName":"Tehrani","suffix":""},{"id":349919058,"identity":"5a4f73b0-5db9-400b-8bd9-20e8a9e0dfe1","order_by":6,"name":"Nader Akbari Dilmaghani","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nader","middleName":"Akbari","lastName":"Dilmaghani","suffix":""}],"badges":[],"createdAt":"2024-08-19 10:36:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4937982/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4937982/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00381-025-06790-9","type":"published","date":"2025-03-16T15:57:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66630459,"identity":"4983ca78-6197-4078-8866-49b631344b75","added_by":"auto","created_at":"2024-10-15 04:48:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2104690,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patients, interventions and procedures performed, and outcomes.\u003c/p\u003e","description":"","filename":"F.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4937982/v1/074fb929d83a4929723a8ac7.jpg"},{"id":78689134,"identity":"1dbd94d5-7962-4f96-89e5-54668628671f","added_by":"auto","created_at":"2025-03-17 16:11:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3294886,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4937982/v1/38a8f45d-a89d-4fb2-94fe-3f0cfb089594.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical and Surgical Outcomes of Pediatric Cushing's Disease Following Endoscopic Transsphenoidal Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCushing's disease (CD) is a pathological state characterized by hypercortisolism, occurring when a pituitary adenoma secretes an excessive amount of adrenocorticotropic hormone (ACTH). Hypercortisolemia, marked by elevated cortisol secretion, is attributed to the presence of a pituitary corticotrophic adenoma. While predominantly reported in adults, this phenomenon can also occur in children, albeit rarely [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The occurrence of CD in children is estimated to be around 5% of that observed in adults [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. CD accounts for 70% of cases of adult-onset endogenous Cushing\u0026rsquo;s syndromes and 75\u0026ndash;80% of cases of pediatric-onset endogenous Cushing\u0026rsquo;s syndromes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It is associated with severe illness in both pediatric and adult patients; hence, early diagnosis and treatment are crucial for optimal therapeutic outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePituitary radiotherapy and transsphenoidal pituitary surgery are considered the most effective therapeutic options for these patients. The clinical presentations of hypercortisolemia can exhibit substantial variation across all age groups, frequently complicating the establishment of a precise diagnosis. Moreover, the initial symptoms of pediatric CD may be underestimated and differ from those observed in adult patients [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Typical observations in pediatric CD include growth retardation with weight gain, a higher occurrence in males, and abnormal puberty [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although there are documented differences in the onset of CD in adults and children, the diagnostic criteria and investigation methodologies for pediatric cases are typically derived from established practices for adults.\u003c/p\u003e \u003cp\u003eThe primary goal of treating CD is to quickly normalize cortisol levels, especially in children, due to the adverse effects of prolonged high cortisol levels on growth and development [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Endoscopic Transsphenoidal Surgery (ETSS) is the recommended first-line treatment for both children and adults with CD, involving the targeted surgical removal of the adenoma. ETSS in children presents technical challenges and requires specialized care from a highly trained pediatric neurosurgeon [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Consistently undetectable serum cortisol levels (less than 50 nmol/l) within a week post-surgery are regarded as the most reliable indicator of successful treatment for CD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The primary aim of this study is to evaluate the clinical and surgical outcomes in pediatric patients with CD, a rare condition with limited prior investigations.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eFrom 2011 to 2024, a total of 3,280 patients with pituitary adenoma underwent surgery using the ETSS technique at Loghman Hospital of Tehran. Among these patients, 213 were diagnosed with CD, and 22 were pediatric cases with age not exceeding 18-years-old (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A retrospective investigation was conducted on 22 consecutive pediatric patients with CD who underwent transsphenoidal microsurgery. The clinical data collected included age, gender, presenting symptoms, family and medical history, imaging characteristics, operative findings such as Hardy-Wilson classification and adenoma size, pathology results, follow-up, and postoperative outcomes, including diabetes insipidus, complications, and current endocrine status.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe Hardy-Wilson classification assessed the level of damage to the sellar region (grade) and the extent of expansion beyond the sellar region (stage) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Extrasellar extension, according to the Hardy-Wilson modified scale, is categorized into different stages: Stage 0 indicates no suprasellar extension, Stages A-C represent progressive suprasellar extension (A indicates occupation of the cistern, B indicates destruction of the recess of the third ventricle, and C indicates gross displacement of the third ventricle), and Stages D-E represent parasellar extension (D indicates intracranial extension and E indicates cavernous sinus extension).\u003c/p\u003e \u003cp\u003e All patients provided written informed consent before enrolment. Institutional review board approval was waived as deidentified information of patients was retrospectively collected.\u003c/p\u003e \u003cp\u003eDiagnostic Evaluation:\u003c/p\u003e \u003cp\u003eA multidisciplinary panel comprising members from the Departments of Endocrinology, Neurosurgery, Radiology, and Pathology established the diagnosis of CD. The diagnosis was confirmed through biochemical tests, including urine free cortisol (UFC), daytime serum ACTH, and low-dose and high-dose dexamethasone suppression tests (LDSST and HDDST). The diagnostic criteria included tumor detection via contrast-enhanced MRI or dynamic gadolinium-enhanced MRI, sustained hypercortisolism confirmed by morning and evening plasma cortisol levels, 24-hour UFC levels, LDDST, HDDST, or contrast-enhanced MRI, along with positive results from inferior petrosal sinus sampling (IPSS) to rule out the presence of a tumor. If no tumors were identified or if there were suspicions, IPSS was performed according to the protocol described by Feng [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOperation and Post-operation\u003c/p\u003e \u003cp\u003eAll ETSS operations were performed by the same surgical team supervised by the senior author (G.Sh). The surgical techniques and informed consent were discussed, considering the patient's age, history, and disease severity. Upon the discovery of an adenoma during surgery, expanded adenomectomy (removal of both the adenoma and the surrounding pituitary tissue) was performed.\u003c/p\u003e \u003cp\u003ePostoperative clinical and endocrinological evaluations were conducted within 7 days after surgery to assess remission and within 6 months after surgery to determine residual disease. Patients were classified as being in remission if they exhibited clinical adrenal insufficiency and had serum cortisol levels below 2.5 \u0026micro;g/dL at 48 hours after surgery or below 1.8 \u0026micro;g/dL with a low-dose dexamethasone suppression test in the third month postoperative. Additionally, they needed to show a restoration of their circadian rhythm, improvement in symptoms, and no evidence of an adenoma in MR imaging.\u003c/p\u003e \u003cp\u003ePersistent illness was characterized by higher postoperative cortisol levels and a requirement for further CD therapy within a 6-month period. Additionally, gadolinium-enhanced and/or dynamic gadolinium-enhanced MRI of the pituitary gland was employed to validate the reappearance of the condition [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOut of the 22 patients, 16 were young females and 6 were young males, with an average age of 14.73 years (range 11\u0026ndash;17). Obesity was the initial clinical manifestation in 59% of the patients, while menstrual problems and striae were reported in 18.2% of the patients. None of the patients had a family history of MEN Syndrome, but 4.54% had a family history of CD. Regarding their medical history, 22.72% had a history of fatty liver, 13.63% had dyslipidemia, 9.09% had diabetes mellitus, and 4.54% were in a pre-diabetic state. Detailed demographic and medical history information is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Demographic and Clinical Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDuration of Symptoms (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFirst Manifestation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFamily History of Pituitary Adenoma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFamily History of MEN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePast Medical History\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(28 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMenstural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMenstural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFat Liver, Dyslipidemia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(12 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(12 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(30 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHTN, Fat Liver\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStriae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes (her cousin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFat Liver\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(30 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(12 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMenstural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHTN, Fat Liver, Dyslipidemia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(30 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStriae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(13 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(24 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHTN, DM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBlurred vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(30 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFat Liver, Dyslipidemia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStriae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(15 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(15 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMenstural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePre DM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003cp\u003e(28 Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOTAL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(11\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale:\u003c/p\u003e \u003cp\u003e% (16/22)\u003c/p\u003e \u003cp\u003eMale:\u003c/p\u003e \u003cp\u003e% (6/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean 18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBlurred vision:\u003c/p\u003e \u003cp\u003e(1/21)\u003c/p\u003e \u003cp\u003eObesity:\u003c/p\u003e \u003cp\u003e(13/22)\u003c/p\u003e \u003cp\u003eMenstural disorder:\u003c/p\u003e \u003cp\u003e(4/22)\u003c/p\u003e \u003cp\u003eStriae: (3/22)\u003c/p\u003e \u003cp\u003eHeadache: (1/21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFamily History of Pituitary Adenoma:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFH MEN:\u003c/p\u003e \u003cp\u003e0% (0/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHTN: (4/22)\u003c/p\u003e \u003cp\u003eDM: (2/22)\u003c/p\u003e \u003cp\u003ePre DM: (1/22)\u003c/p\u003e \u003cp\u003eFat Liver: (5/22)\u003c/p\u003e \u003cp\u003eDyslipidemia: (3/22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the Hardy-Wilson classification, 18.2% of patients were classified as stage E, 9.09% as stage C, and the rest (excluding MRI-negative patients) as stage A. Additionally, 18.2% of patients exhibited invasion into the cavernous sinus, and 9.09% showed evidence of hemorrhagic sella on their imaging.\u003c/p\u003e \u003cp\u003eAll patients underwent ETSS surgical treatment (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among them, 18.2% also underwent total hypophysectomy, and 9.09% underwent hemi-hypophysectomy. Radiation therapy was performed in 9.09% of patients, with one patient eligible for bilateral adrenalectomy. No surgical complications developed except for cerebrospinal fluid (CSF) leakage, which was observed in 13.63% of patients. Further details on the surgical treatments are provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical and Treatment Details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSize of Adenoma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultifocality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInvasion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHardy-Wilson Classification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdditional Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNumber of surgeries\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSurgical Approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eResection\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMacro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCavernous Sinus Knosb 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFirst Op: 3E\u003c/p\u003e \u003cp\u003e2nd Op: 3E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 ( Same surgeon)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHemorrhagic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd Op: Micro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCavernous Sinus Knosb 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2nd Op: 1E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (Other surgeon)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHemi-hypophysectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI Neg.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMacro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI Neg.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal-hypophysectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMacro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCavernous Sinus Knosb 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmpty sella,\u003c/p\u003e \u003cp\u003eHemorragic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHemi-hypophysectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMacro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal-hypophysectomy, Stalkectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst Op: Micro\u003c/p\u003e \u003cp\u003e2nd Op: MRI Neg.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFirst Op: Multifocal\u003c/p\u003e \u003cp\u003e2nd Op: 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst Op: Cavernous Sinus Knosb 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFirst Op:2E\u003c/p\u003e \u003cp\u003e2nd Op: 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 ( Same surgeon)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd Op: Micro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2nd Op : 1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (Other surgeon)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMacro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal-hypophysectomy,\u003c/p\u003e \u003cp\u003eStalkectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal-hypophysectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd Op: Micro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnifocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2nd Op : 1A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (Other surgeon)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdenomectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOTAL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLast Op;\u003c/p\u003e \u003cp\u003eMicro:\u003c/p\u003e \u003cp\u003e(14/22)\u003c/p\u003e \u003cp\u003eMacro:\u003c/p\u003e \u003cp\u003e(5/22)\u003c/p\u003e \u003cp\u003eMRI Neg: (3/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast Op; Unifocal:\u003c/p\u003e \u003cp\u003e% (16/22)\u003c/p\u003e \u003cp\u003eMultifocal:\u003c/p\u003e \u003cp\u003e% (3/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLast Op; Cavernous Sinus Invasion:\u003c/p\u003e \u003cp\u003eKnosb 1:\u003c/p\u003e \u003cp\u003e% (2/22)\u003c/p\u003e \u003cp\u003eKnosb 2:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLast Op;\u003c/p\u003e \u003cp\u003e1A: % (14/22)\u003c/p\u003e \u003cp\u003e2C: % (2/22)\u003c/p\u003e \u003cp\u003e1E: % (1/22)\u003c/p\u003e \u003cp\u003e2E: % (1/22)\u003c/p\u003e \u003cp\u003e3E: % (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHemorrhagic Tumor:\u003c/p\u003e \u003cp\u003e% (2/22)\u003c/p\u003e \u003cp\u003eEmpty Sella:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 Op :\u003c/p\u003e \u003cp\u003e% (17/22)\u003c/p\u003e \u003cp\u003e2 Op:\u003c/p\u003e \u003cp\u003e% (5/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eETSS:\u003c/p\u003e \u003cp\u003e100% (22/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLast Op: Adenomectomy:\u003c/p\u003e \u003cp\u003e% (16/22)\u003c/p\u003e \u003cp\u003eHemihypophysectomy:\u003c/p\u003e \u003cp\u003e% (2/22)\u003c/p\u003e \u003cp\u003eTotal Hypophysectomy:\u003c/p\u003e \u003cp\u003e% (4/22)\u003c/p\u003e \u003cp\u003eStalkectomy :\u003c/p\u003e \u003cp\u003e% (2/22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, 95.45% of patients went into remission, while the rest did not respond to the surgical treatment. Additionally, 4.54% of patients experienced a recurrence of CD after achieving remission and required re-operation. Temporary diabetes insipidus occurred in 40.09% of patients. Most patients experienced hormone imbalances following surgery, with 50% experiencing hypocortisolism, 45.45% hypothyroidism, and 13.63% hypogonadism. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides more details on surgical outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Complications \u0026amp; Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImmediate Complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdditional Treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFollow-up Period (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLong-Term Complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePost Op DI\u003c/p\u003e \u003cp\u003e(No, Temporary, Permanent)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLast Endocrine Status\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRadiotherapy, Bilateral Adrenalectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMenstural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypogonadism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCSF Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMenstural disorder, Insulin Resistance, Dyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCSF Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpistaxis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInfertility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypogonadism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN, Dyslipidemia, Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCSF Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMenstural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRadiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElectrolyte Imbalance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInsulin Resistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRecurrence after Remission (after 2 years of Op)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOsteopenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism, Hypogonadism, Hypocortisolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOTAL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCSF Leak:\u003c/p\u003e \u003cp\u003e% (3/22)\u003c/p\u003e \u003cp\u003eEpistaxis:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003cp\u003eElectrolyte Imbalance:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRadiotherapy:\u003c/p\u003e \u003cp\u003e% (2/22)\u003c/p\u003e \u003cp\u003eBilateral Adrenalectomy:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.3 Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHTN : % (2/22)\u003c/p\u003e \u003cp\u003eDyslipidemia:\u003c/p\u003e \u003cp\u003e% (2/22)\u003c/p\u003e \u003cp\u003eOsteopenia:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003cp\u003eInsulin Resistance:\u003c/p\u003e \u003cp\u003e% (2/22)\u003c/p\u003e \u003cp\u003eMenstural disorder:\u003c/p\u003e \u003cp\u003e% (3/22)\u003c/p\u003e \u003cp\u003eDepression:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemission:\u003c/p\u003e \u003cp\u003e% (19/22)\u003c/p\u003e \u003cp\u003eNo Response:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003cp\u003eRecurrence after Remission:\u003c/p\u003e \u003cp\u003e% (1/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDI\u003c/p\u003e \u003cp\u003eNo:\u003c/p\u003e \u003cp\u003e% (13/22)\u003c/p\u003e \u003cp\u003eTemporary:\u003c/p\u003e \u003cp\u003e% (9/22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHypocortisolism:\u003c/p\u003e \u003cp\u003e% ( 11/22 )\u003c/p\u003e \u003cp\u003eHypogonadism:\u003c/p\u003e \u003cp\u003e% ( 3/22 )\u003c/p\u003e \u003cp\u003eHypothyroidism:\u003c/p\u003e \u003cp\u003e% ( 10/22 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the past, bilateral adrenalectomy was commonly used as the first-line treatment. While the method successfully reduced cortisol levels, there was still a danger of developing Nelson's syndrome after undertaking adrenalectomy for pituitary adenoma. Medical intervention aimed at reducing cortisol levels is a potential short-term treatment option, but it is not advisable as the primary therapy for Cushing's disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Transsphenoidal pituitary surgery is the preferred option for young patients with CD, as it allows for the targeted excision of the microadenoma [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Both transsphenoidal microscopic surgery (TSMS) and ETSS offer a safe and effective approach to accessing the sellar fossa, with a minimal incidence of complications and morbidity.\u003c/p\u003e \u003cp\u003eThe introduction of endoscope has led to significant advancements in transsphenoidal surgery. Currently, ETSS is the preferred procedure for pituitary surgery. We made the switch to ETSS in 2006 because it is less invasive than TSMS, while still achieving the same rates of full tumor removal. Additionally, patients who have ETSS have shorter hospital stays, both in adults and children [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe clinical manifestations of CD typically result from elevated cortisol production. The presentation exhibits significant variability. The diagnosis is often delayed due to the reason that growth failure may be the sole symptom for an extended period of time. Our series indicates that obesity and weight gain are the most common and initial symptoms of CD in pediatric patients. This finding is further supported by earlier research [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSeveral elements of CD exhibit variations in the pediatric population. The frequency is greater in males than in females. Unlike prior works [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], our dataset exhibited an obvious female dominance, with females accounting for 72.72% of the total population compared to males at 23%. The significance of gender is evident in a study where it was shown that out of 102 pediatric patients, male participants had greater body mass index (BMI), potentially shorter height, and elevated plasma ACTH levels. This suggests that boys may have a more aggressive type of CD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn our study, 95.45% of patients experienced remission during the initial follow-up period and one patient experienced recurrence. One of our patients, who did not experience a successful recovery following their second surgery follow-up, was considered as a candidate for bilateral adrenalectomy. Out of these patients, 5 (22.72%) have previously undergone endoscopic operations, following the repeated ETSS procedure on these 5 patients, 4 of them successfully attained remission. There is a lack of evidence on the rates of remission of CD after undergoing repeat transsphenoidal surgery, with reported proportions varying between 28.9% and 73% [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The rates of recurrent CD after reoperation exhibit variability, with presented incidences ranging from 22\u0026ndash;63.2% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, it is important to note that this data specifically pertains to adult patients with CD. Additionally, there is insufficient evidence about the rate of remission and recurrence after repeating ETSS in pediatric patients.\u003c/p\u003e \u003cp\u003eTwo patients had radiotherapy for the treatment of CD. Non-surgical alternatives, such as radiotherapy and radiosurgery, have been regarded useful for recurring or residual CD due to their low morbidity rates and appropriate remission rates [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, for radiosurgery the remission rate varies across individuals. Therefore, it is important to acknowledge that ETSS provides much higher remission rate for microadenomas [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, our research, similar to the study conducted by Hanalioglu et.al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], indicates that the results and rates of complications related to repeated ETSS are similar to those of the initial ETSS for CD and better than alternative non-surgical treatments for persistent or recurring CD. Within our study, a total of 3 patients (13.63%) experienced rhinorrhea and required reoperation. This aligns with previously reported rates of CSF leakage, which typically ranges from 1 to 5%, after repeating endoscopic transsphenoidal surgery for residual or recurrent pituitary tumors [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOut of the patients we studied, 9 individuals (40.09%) had temporary diabetes insipidus (DI), Similarly, other studies have documented rates of DI ranging from 2 to 13% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, none of them acquired persistent DI. In addition, 50% of patients acquired hypocortisolism and 13.63% of patients had hypogonadism. While hypothyroidism developed in 45.45% of patients. According to a prior study, it is found that all four axis of preoperative pituitary deficit showed recovery, with an average recovery rate of 29.7%. The cortisol axis exhibited the most significant recovery, while the thyroid axis shown the least recovery, with cumulative recovery rates of 44.3% and 6.1% respectively, over the course of one year. Postoperative hypopituitarism was observed in 17.2% of cases, with the highest incidence in the thyroid axis (24.3%, 27 out of 111) and the lowest incidence in the cortisol axis (9.7%, 16 out of 165) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on our results, 13.63% of our patients had negative MRI findings. However, all of these children obtained remission after undergoing surgery. In contrast, a study conducted by Tatsi et.al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] suggests that the remission rate in these MRI-negative patients is significantly lower compared to pediatric patients with positive MRI results. Also, it is important to note that empty sella is a condition commonly associated with pituitary adenomas especially somatotropic adenomas, as reported by Sharifi et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] in their previous series.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStrength and Limitation\u003c/h2\u003e \u003cp\u003eOur study is one of the largest case series in the existing literature that investigates the safety, feasibility, and effectiveness of ETSS for the management of recurring and diagnosed pediatric Cushing\u0026rsquo;s disease. The results of our study emphasize the safety and effectiveness of ETSS at specialized medical facilities, demonstrating high rates of successful treatment and minimal complication rates. Nevertheless, it is crucial to acknowledge the retrospective nature of our work, which automatically brings about potential biases such as selection bias.\u003c/p\u003e \u003cp\u003eOur study specifically examines individuals who have undergone surgery for residual CD in pediatric. This limits our capacity to evaluate the effectiveness of surgical treatment with alternative methods like as radiation or radiosurgery.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the effectiveness and safety of endoscopic transsphenoidal surgery in the management of Cushing's disease. Surprisingly, a significant proportion of patients (95.45%) experienced remission following their reoperation. In addition, the rates of complications observed in our study group were in line with the recorded rates for both initial and repeated transsphenoidal procedures. Endoscopic transsphenoidal surgery is a dependable and secure therapy method for Cushing's disease in pediatric patients, providing acceptable rates of remission along with minimal complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eG.SH ConceptualizationEP and MMMN writing the manuscriptEM Review editing NS and MRMT: investigationNAD: Supervision\u003c/p\u003e\u003ch2\u003eAcknowledgment\u003c/h2\u003e \u003cp\u003eAuthors declare that they used OpenAI\u0026rsquo;s ChatGPT in a supervised manner only to revise the language and readability of current are very grateful for the patience and trust of our patients and their families. Also, we appreciate the hard works of our coworkers and other researchers.\u003c/p\u003e\u003ch2\u003eAvailability of data\u003c/h2\u003e \u003cp\u003eAll data used in this manuscript are available as deidentified material through direct request sent to corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSavage MO, Dias RP, Chan LF, Afshar F, Plowman NP, Matson M et al (2010) Diagnosis and treatment of Cushing\u0026rsquo;s disease in children. Pediatr Neuroendocrinol 17:134\u0026ndash;145\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuaraldi F, Storr HL, Ghizzoni L, Ghigo E, Savage MO (2014) Paediatric pituitary adenomas: a decade of change. Hormone Res paediatrics 81(3):145\u0026ndash;155\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStorr HL, Drake WM, Evanson J, Matson M, Berney DM, Grossman AB et al (2014) Endonasal endoscopic transsphenoidal pituitary surgery: early experience and outcome in paediatric C ushing's disease. Clin Endocrinol 80(2):270\u0026ndash;276\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026uuml;emes M, Murray PG, Brain CE, Spoudeas HA, Peters CJ, Hindmarsh PC, Dattani MT (2016) Management of Cushing syndrome in children and adolescents: experience of a single tertiary centre. Eur J Pediatrics 175:967\u0026ndash;976\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLonser RR, Wind JJ, Nieman LK, Weil RJ, DeVroom HL, Oldfield EH (2013) Outcome of surgical treatment of 200 children with Cushing's disease. J Clin Endocrinol Metabolism 98(3):892\u0026ndash;901\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJagannathan J, Dumont AS, Jane JA, Laws ER (2005) Pediatric sellar tumors: diagnostic procedures and management. NeuroSurg Focus 18(6):1\u0026ndash;5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLibuit LG, Karageorgiadis AS, Sinaii N, Nguyen May NM, Keil MF, Lodish MB, Stratakis CA (2015) A gender-dependent analysis of Cushing's disease in childhood: pre‐and postoperative follow‐up. Clin Endocrinol 83(1):72\u0026ndash;77\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu X, Dai C, Bao X, Deng K, Yao Y, Sun B et al (2021) Treatment and outcomes of recurrent/persistent Cushing\u0026rsquo;s disease: a single-center experience. Annals Palliat Med 10(3):2494504\u0026ndash;2492504\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValderr\u0026aacute;bano P, Aller J, Garc\u0026iacute;a-Valdecasas L, Garc\u0026iacute;a-Ur\u0026iacute;a J, Mart\u0026iacute;n L, Palacios N, Estrada J (2014) Results of repeated transsphenoidal surgery in Cushing's disease. Long-term follow-up. Endocrinolog\u0026iacute;a y Nutrici\u0026oacute;n (English Edition) 61(4):176\u0026ndash;183\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang B, Zheng S, Ren J, Zhong Z, Jiang H, Sun Q et al (2022) Reoperation for recurrent and persistent Cushing\u0026rsquo;s disease without visible MRI findings. J Clin Med 11(22):6848\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakiri F, Tatai S, Aouali R, Semrouni M, Derome P, Chitour F, Benmiloud M (1996) Treatment of Cushing\u0026rsquo;s disease by transsphenoidal, pituitary microsurgery: prognosis factors and long-term follow-up. J Endocrinol Investig 19:572\u0026ndash;580\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDickerman RD, Oldfield EH (2002) Basis of persistent and recurrent Cushing disease: an analysis of findings at repeated pituitary surgery. J Neurosurg 97(6):1343\u0026ndash;1349\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNegm HM, Al-Mahfoudh R, Pai M, Singh H, Cohen S, Dhandapani S et al (2017) Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg 127(2):397\u0026ndash;408\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastinetti F, Brue T, Ragnarsson O (2019) Radiotherapy as a tool for the treatment of Cushing\u0026rsquo;s disease. Eur J Endocrinol 180(5):D9\u0026ndash;D18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrady Z, Garrahy A, Carthy C, O\u0026rsquo;Reilly MW, Thompson CJ, Sherlock M et al (2021) Outcomes of endoscopic transsphenoidal surgery for Cushing's disease. BMC Endocr Disorders 21(1):36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12902-021-00679-9\u003c/span\u003e\u003cspan address=\"10.1186/s12902-021-00679-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanalioglu S, Gurses ME, Gecici NN, Baylarov B, Isikay I, G\u0026uuml;rlek A, Berker M (2024) Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent cushing\u0026rsquo;s disease: safety, feasibility, and success. Pituitary :1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavallo LM, Solari D, Tasiou A, Esposito F, de Angelis M, D'Enza AI, Cappabianca P (2013) Endoscopic endonasal transsphenoidal removal of recurrent and regrowing pituitary adenomas: experience on a 59-patient series. 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Front Surg 11:1350032\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cushing's disease, Pediatric endocrinology, Endoscopic transsphenoidal surgery, Pituitary adenoma, Hypercortisolism, Surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4937982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4937982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCushing's disease (CD) is characterized by hypercortisolism due to excessive adrenocorticotropic hormone (ACTH) secretion from a pituitary adenoma. Though more common in adults, pediatric cases constitute approximately 5% of those seen in adults. Early diagnosis and treatment are critical due to the severe impacts on growth and development in children. Endoscopic transsphenoidal surgery (ETSS) is the preferred first-line treatment for both children and adults.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom 2011 to 2024, 3,280 patients with pituitary adenoma underwent surgery using the ETSS technique at Loghman Hospital of Tehran, including 213 CD cases, of which 22 were pediatric (under 18 years old). This retrospective study analyzed clinical data such as age, gender, presenting symptoms, family and medical history, imaging characteristics, surgical findings, pathology, follow-up, and postoperative outcomes. Diagnostic criteria included biochemical tests, MRI imaging, and inferior petrosal sinus sampling.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of 22 pediatric patients, 16 were females and 6 males, with an average age of 14.73 years. Obesity was the initial clinical manifestation in 59% of the patients. According to the Hardy-Wilson classification, 18.2% of patients were stage E, 9.09% stage C, and the rest (excluding MRI-negative patients) stage A. ETSS was performed on all patients, with total hypophysectomy in 18.2% and hemi-hypophysectomy in 9.09%. Postoperative complications included cerebrospinal fluid leakage in 13.63% of patients. Remission was achieved in 95.45% of patients, with a recurrence rate of 4.54%. Hormone imbalances post-surgery included hypocortisolism (50%), hypothyroidism (45.45%), and hypogonadism (13.63%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eETSS is an effective and safe treatment for pediatric CD, achieving high remission rates and minimal complications. This study highlights the importance of specialized surgical care in managing pediatric CD and underscores the need for early diagnosis and intervention. Further studies are warranted to evaluate long-term outcomes and optimize treatment protocols.\u003c/p\u003e","manuscriptTitle":"Clinical and Surgical Outcomes of Pediatric Cushing's Disease Following Endoscopic Transsphenoidal Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 04:48:01","doi":"10.21203/rs.3.rs-4937982/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-05T09:27:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-02T10:05:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-30T08:26:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210216457313115564009056648402831181779","date":"2024-08-24T08:27:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11100269697883204495478581789833960949","date":"2024-08-21T18:48:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-21T17:27:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-20T03:48:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-20T03:47:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-08-19T10:34:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"31572a3b-ac9c-4d45-ac56-55046e4c98ff","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T16:06:45+00:00","versionOfRecord":{"articleIdentity":"rs-4937982","link":"https://doi.org/10.1007/s00381-025-06790-9","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2025-03-16 15:57:52","publishedOnDateReadable":"March 16th, 2025"},"versionCreatedAt":"2024-10-15 04:48:01","video":"","vorDoi":"10.1007/s00381-025-06790-9","vorDoiUrl":"https://doi.org/10.1007/s00381-025-06790-9","workflowStages":[]},"version":"v1","identity":"rs-4937982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4937982","identity":"rs-4937982","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}