Effect of pituitary stalk preservation during craniopharyngioma removal on pituitary function, extent of resection, and recurrence: systematic review and meta-analysis

OBJECTIVE Optimal management of the pituitary stalk during craniopharyngioma resection remains a controversial subject. This meta-analysis aimed to evaluate the effect of pituitary stalk preservation on postoperative diabetes insipidus (DI), anterior pituitary function (PF), extent of resection, and recurrence. METHODS Medline was searched via Ovid for relevant articles from inception to September 2, 2022. Studies reporting the rates of DI or anterior PF postoperatively or at last follow-up, extent of resection, or tumor recurrence at last follow-up were eligible for inclusion. The risk ratio (RR) for each outcome was calculated. Random-effects meta-analyses were performed with additional stratification by age. To assess for risk of bias across studies, funnel plots and the Egger’s test were utilized. RESULTS In total, 3488 abstracts and 150 full-text articles were reviewed, resulting in 33 studies with a total of 2366 patients for inclusion. In the comparative meta-analysis, pituitary stalk preservation significantly decreased the risk of DI postoperatively (17 studies, RR 0.67, 95% CI 0.55–0.81, I 2 = 75%), DI at last follow-up (6 studies, RR 0.54, 95% CI 0.41–0.72, I 2 = 20%), and abnormal anterior PF postoperatively (15 studies, RR 0.78, 95% CI 0.69–0.89, I 2 = 49%) but not abnormal anterior PF at last follow-up (4 studies, RR 0.38, 95% CI 0.09–1.63, I 2 = 64%). There were no significant differences in the rates of incomplete resection (12 studies, RR 1.59, 95% CI 0.77–3.28, I 2 = 68%) or tumor recurrence (9 studies, RR 1.18, 95% CI 0.92–1.51, I 2 = 0%) between the preservation and sacrifice groups. However, subgroup analysis of pediatric patients revealed a higher risk of incomplete resection (RR 3.29, 95% CI 1.17–9.26, I 2 = 70%) in the stalk preservation group. CONCLUSIONS Pituitary stalk preservation was demonstrated to confer protective benefit on PF, although the benefit persisted on long-term follow-up for posterior PF only. Stalk preservation in pediatric patients should be given careful consideration, as it is associated with higher rates of incomplete resection. These results should be interpreted with caution due to inclusion of small studies and inadequate reporting of outcomes in the literature.