Abstract

Background: Craniopharyngiomas pose a significant clinical challenge due to their complex anatomical location and potential for neurological sequelae. Surgical management options include transcranial and endoscopic approaches, each with its advantages and limitations. This systematic review and meta-analysis aims to comprehensively compare the outcomes of transcranial and endoscopic surgery for craniopharyngioma, integrating the latest evidence from ten pertinent journal articles.

Methods: A systematic search of electronic databases, including Google Scholar, PubMed, MEDLINE, and Embase, was conducted to identify relevant studies published between 2010 and 2022. A total of eight articles comparing outcomes of transcranial and endoscopic surgery for craniopharyngioma were included in the study. Data extraction and quality assessment were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: The transcranial approach was less effective in achieving gross total resection (odds ratio [OR] = 0.47, 95% confidence interval [CI] = 0.32–0.70) compared to the endoscopic approach, with low heterogeneity (I² = 41%). However, both approaches had similar odds for near-total resection, subtotal resection, and partial resection. The transcranial approach was associated with lower odds of total neurological complications (OR = 0.6, 95% CI = 0.4–0.9), higher odds of tumor recurrence (OR = 1.86, 95% CI = 1.12–3.09), and lower odds of visual improvement (OR = 0.43, 95% CI = 0.32–0.58) compared to the endoscopic approach. There was no significant difference in mortality rate between the two approaches.

Conclusion: Our meta-analysis comparing the efficacy of transcranial and endoscopic surgery for craniopharyngioma reveals that the endoscopic approach is preferred for managing specific conditions due to its higher likelihood of achieving complete resection and potentially better postsurgery outcomes, minimizing neurological complications.

Keywords: Craniopharyngioma, Endoscopic, Resection, Transcranial

INTRODUCTION

Craniopharyngiomas pose significant challenges in neurosurgical practice due to their complex anatomical proximity to critical brain structures. Surgical resection remains crucial, aiming to maximize tumor removal while minimizing neurological morbidity.[ 14 ] Two primary approaches, transcranial and endoscopic, have emerged as mainstays in craniopharyngioma surgery, each offering unique advantages and limitations.[ 12 ]

The literature has extensively explored these approaches. Early seminal work by Campbell et al., followed by contributions from Jeswani et al., established foundational insights into transcranial and endoscopic techniques, respectively.[ 2 , 8 ] Subsequent studies by Ozgural et al. and Fan et al. have highlighted evolving surgical outcomes, emphasizing tailored treatment strategies.[ 5 , 17 ]

Concurrently, investigations by Li et al. and Komotar et al. underscored the impact of surgical approaches on complications and functional outcomes, guiding clinical decision-making.[ 10 , 12 ] Recent studies by Nie et al., Marx et al., and Wu et al. further enriched our understanding of modern surgical techniques and their implications.[ 13 , 15 , 20 ]

However, gaps persist in understanding the comparative effectiveness of these approaches, especially concerning their outcomes in achieving complete resection and minimizing complications. This systematic review and meta-analysis aims to address these gaps, synthesizing the latest evidence from 2010 to 2022. By analyzing key studies, we seek to provide a comprehensive evaluation of the comparative efficacy of transcranial versus endoscopic surgery for craniopharyngioma. This synthesis aims to inform neurosurgeons’ clinical decisions, optimize surgical outcomes, and enhance care for patients with this challenging condition.

MATERIALS AND METHODS

Literature search strategy

A comprehensive literature search was conducted across multiple electronic databases, including Google Scholar, PubMed, MEDLINE, Cochrane Library, and Embase, to identify relevant studies published between January 2010 and January 2022. This study combine MeSH and an advanced search strategy designed to capture all studies comparing the efficacy of transcranial and endoscopic surgery for craniopharyngioma. The search terms included variations of “craniopharyngioma,” “transcranial surgery,” “endoscopic surgery,” “comparative study,” and “surgery outcomes.”

Study selection criteria

Studies were included in the review if they met the following criteria: (1) comparative study design comparing transcranial and endoscopic surgery for craniopharyngioma, (2) publication in a peer-reviewed journal between January 2010 and January 2022, (3) availability of relevant outcome data such as surgical outcomes, perioperative complications, and long-term functional outcomes, and (4) inclusion of human subjects of any age group.

Screening and data extraction

Initially, duplicates were removed, and titles and abstracts of the remaining articles were screened independently by two reviewers to assess their eligibility for inclusion. Full-text articles of potentially relevant studies were then retrieved and assessed for final inclusion based on the predefined criteria. Any discrepancies were resolved through discussion and consensus. Data were extracted from included studies using a standardized form, capturing information on study characteristics, patient demographics, surgical techniques, and outcome measures.

Quality assessment

The methodological quality of the included studies was evaluated using appropriate tools depending on the study design. Randomized controlled trials were assessed using the Cochrane Collaboration’s tool for assessing the risk of bias, while nonrandomized studies were evaluated using the Newcastle–Ottawa Scale for observational studies. Quality assessment was performed independently by two reviewers, with any discrepancies resolved through discussion and consultation with a third reviewer if necessary.

Statistical analysis

Quantitative data synthesis was conducted using Review Manager 5.4 (Revman) software. Pooled effect sizes and corresponding 95% confidence intervals (CIs) were calculated for relevant outcome measures, including overall survival rates, perioperative complications, and functional outcomes. Heterogeneity across studies was assessed using Cochran’s Q test and the I² statistic. Subgroup analyses and sensitivity analyses were conducted where appropriate to explore sources of heterogeneity and assess the robustness of findings.

Protocol registration

The protocol for this systematic review and meta-analysis was registered in advance with an appropriate registry PROSPERO to ensure transparency and adherence to predefined methods. The study has already registered to PROSPERO with (ID: 525683). Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart is described in Figure 1 .

Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.

RESULTS

Characteristics of included studies

Eight eligible cohort studies were included in this systematic review and meta-analysis, comprising 971 patients. Table 1 presents the study design, country, number of patients in each observed group, mean age, proportion of male patients, mean tumor size, mean follow-up time, craniopharyngioma histopathology, and measured outcomes across studies. Most of the studies were conducted in Asia.[ 3 - 5 , 7 , 9 - 11 ] There are varying outcomes measured between studies, and we have compiled outcomes of interest in this study from the included studies in Table 2 . The consistently reported outcomes, as measured by at least two studies, include the extent of resection (gross total resection [GTR], near-total resection [NTR], subtotal resection [STR], and partial resection), total neurology-related complications, recurrence rate, mortality rate, and improved visual outcomes. Therefore, we only analyzed these outcomes in the meta-analysis.

Table 1:

Characteristics of included studies.

Table 2:

Measured outcomes.

Risk of bias assessment

Most of the studies included in this analysis were retrospective in design [ Table 3 ],[ 3 - 5 , 7 , 8 , 11 , 12 ], with only one study having a prospective design.[ 4 ] Based on the assessment using the Newcastle–Ottawa Scale for cohort studies, the overall risk of bias in the included studies was low. However, one study had a moderate risk of bias due to incomplete reporting of the follow-up. A study had a relatively short follow-up time of <12 months; however, the overall risk of bias was low.[ 9 ]

Table 3:

Risk of bias assessment.

Meta-analysis of measured outcomes

When comparing the extent of resection, studies reported different results, including GTR, NTR, STR, and partial resection. The meta-analysis revealed that the transcranial approach resulted in lower odds of achieving GTR (odds ratio [OR] = 0.47, 95% CI = 0.32–0.70, P = 0.0002) compared to the endoscopic approach [ Figure 2a ]. The reported GTR between studies showed no substantial heterogeneity (I² = 41%). In contrast, the transcranial approach resulted in similar odds of achieving NTR (OR = 0.9, 95% CI = 0.13–6.15, P = 0.91); [ Figure 2b ], STR (OR = 1.81, 95% CI = 0.66–4.95, P = 0.25); [ Figure 2c ], and partial resection (OR = 1.38, 95% CI = 0.06–32.93, P = 0.84); [ Figure 2d ]. However, there was substantial heterogeneity found between studies (I² = 90%, 60%, and 74%, respectively). The study results suggest that the endoscopic approach is more effective in achieving GTR of craniopharyngioma compared to the transcranial approach.

Figure 2:

Forest plot of measured outcomes. (a) gross total resection, (b) near total resection, (c) subtotal resection, (d) partial resection, (e) total complications, (f) recurrence rate, (g) mortality rate, and (h) improved visual. M-H/CI: Mantel-Haenszel Confidence Interval, a statistical method used in this meta-analysis to calculate a pooled estimate of effect size across multiple studies. The Mantel-Haenszel (M-H) method adjusts for confounding variables by stratifying data, helping reduce bias.

The transcranial approach is associated with lower odds of total neurological complications (OR = 0.6, 95% CI = 0.4–0.9, P = 0.01); [ Figure 2e ]. However, the transcranial approach was found to have higher odds of tumor recurrence (OR = 1.86, 95% CI = 1.12–3.09, P = 0.02); [ Figure 2f ] and lower odds of visual improvement (OR = 0.43, 95% CI = 0.32–0.58, P < 0.00001). Both treatment approaches resulted in an insignificant difference in mortality rate (OR = 1.44, 95% CI = 0.49–4.21, P = 0.51); [ Figure 2g ]. The transcranial approach was found to have lower odd of visual improvement (OR = 0.43, 95% CI = 0.32-0.58, p < 0.00001); [ Figure 2h ]. These results show no significant heterogeneity between studies (I² = 0%).

DISCUSSION

The meta-analysis findings indicate that the transcranial approach, involving a skull incision for brain access, shows significantly lower odds of achieving GTR compared to the endoscopic approach. The OR of 0.47 (95% CI = 0.32–0.70, P = 0.0002) suggests a substantially reduced likelihood of achieving GTR with the transcranial method. This finding underscores the potential superiority of the endoscopic approach in achieving complete tumor or lesion removal, a crucial goal in surgical interventions for improved patient outcomes and reduced recurrence rates. These results could inform clinical decision-making regarding the choice of surgical approach for patients requiring similar interventions, emphasizing the importance of considering both efficacy and invasiveness when determining the most appropriate treatment strategy. The recent study provides support for these findings, even indicating that the endoscopic approach is currently considered the approach of choice when considering GTR.[ 6 , 18 ] However, other studies indicate that there is no discernible distinction between the two methods.[ 9 , 21 ]

A comprehensive analysis of craniopharyngioma surgeries reveals valuable insights into the relationship between surgical techniques and the incidence of neurological complications. Notably, the analysis uncovers a significant finding: The transcranial approach is associated with a reduced likelihood of overall neurological complications when compared to other methods. This discovery has important implications for the way craniopharyngioma is managed in clinical practice, and it can greatly impact patient outcomes. Having a thorough understanding of the intricacies and potential dangers linked to various surgical methods is crucial for enhancing treatment approaches and enhancing patient well-being.[ 9 , 10 , 15 ]

Further investigation and discussion are needed to explore the preference for the transcranial approach in reducing neurological complications. Perhaps the reason behind this connection lies in the transcranial approach, which offers direct access and visualization. This enables a more accurate and controlled manipulation of the brain structures involved in craniopharyngioma resection. On the other hand, different methods, such as endoscopic techniques, can present difficulties in getting the best view and reaching the tumor, which could result in higher chances of neurological complications.[ 3 , 15 ]

It is important to recognize the potential limitations and confounding factors that could impact the observed association. There may be differences in surgical expertise, patient characteristics, tumor complexity, and perioperative care protocols among the studies included in the meta-analysis. These variations could potentially introduce biases and affect how applicable the findings are to the general population. Furthermore, the fact that many studies are conducted retrospectively and the possibility of selection bias highlights the importance of interpreting the results with caution.

The observation that the transcranial approach exhibits higher odds of tumor recurrence alongside lower odds of visual improvement underscores the complexity of surgical decision-making in the management of conditions such as craniopharyngioma. While the transcranial approach offers direct access to the tumor and surrounding structures, facilitating precise resection and potentially reducing the risk of total neurological complications, as previously discussed, the increased odds of tumor recurrence highlight a significant concern for long-term treatment success.[ 19 ]

This finding prompts a critical evaluation of the factors contributing to tumor recurrence following the transcranial approach, including the potential for residual tumor remnants or incomplete resection due to anatomical constraints or technical limitations inherent to this surgical approach. Moreover, the lower odds of visual improvement associated with the transcranial approach raise important considerations regarding the preservation of visual function, a crucial aspect of patient quality of life in craniopharyngioma management. The discrepancy in visual outcomes between surgical approaches may be attributed to various factors, including the extent of tumor manipulation, the proximity of critical visual structures, and the occurrence of surgical complications such as optic nerve injury or ischemia.

The analysis of mortality rates associated with both treatment approaches reveals a crucial aspect of patient outcomes in the management of craniopharyngioma. The finding of an insignificant difference in mortality rates between the two approaches underscores the equipoise in survival outcomes, suggesting that neither the transcranial nor the alternative approach confers a significant advantage or disadvantage in terms of mortality risk. This observation is particularly noteworthy given the paramount importance of patient survival in the context of craniopharyngioma management and highlights the comparable safety profiles of both surgical techniques in this regard.[ 1 , 4 , 16 ]

Moreover, the absence of significant heterogeneity between studies, as indicated by the low I² statistic (0%), lends further credibility to the robustness and consistency of the findings across the included studies. This finding suggests a high degree of agreement among studies regarding the effect of the treatment approach on mortality rates, reinforcing the reliability of the observed association.[ 7 ]

The lack of a significant difference in mortality rates between treatment approaches prompts a critical evaluation of other factors influencing patient outcomes and treatment decisions in craniopharyngioma management. While mortality is undoubtedly a critical endpoint, other clinical factors such as neurological function preservation, tumor control, and quality of life outcomes also play pivotal roles in guiding treatment decisions and optimizing patient care. Therefore, a comprehensive evaluation of the risks and benefits associated with each treatment approach, taking into account various clinical considerations and patient preferences, is essential in ensuring the delivery of personalized and evidence-based care.

The meta-analysis of studies found that the transcranial approach had lower odds of achieving GTR compared to the endoscopic approach. However, the endoscopic approach was more effective in achieving GTR of craniopharyngioma. The transcranial approach was associated with lower odds of total neurological complications but higher odds of tumor recurrence and lower odds of visual improvement. Both treatment approaches resulted in an insignificant difference in mortality rate, with no significant heterogeneity between studies.

CONCLUSION

Ultimately, our analysis comparing the effectiveness of transcranial and endoscopic surgery for craniopharyngioma indicates that the endoscopic approach is more favorable for treating certain conditions. This is because it has a greater chance of achieving complete removal of the tumor and potentially leading to improved outcomes after surgery while also reducing the risk of neurological complications.

Ethical approval

The Institutional Review Board approval is not required because they use pre-existing data from studies that have already undergone ethical review, involve no direct participant interaction, and rely on publicly available information. As a form of secondary research, they do not involve personal or sensitive data.

Declaration of patient consent

Patient’s consent was not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Beckhaus J, Friedrich C, Müller HL. Vascular morbidity and mortality in craniopharyngioma patients-a scoping review. Cancers. 2024. 16: 1099

2. Campbell PG, McGettigan B, Luginbuhl A, Yadla S, Rosen M, Evans JJ. Endocrinological and ophthalmological consequences of an initial endonasal endoscopic approach for resection of craniopharyngiomas. Neurosurg Focus. 2010. 28: E8

3. Diaz MJ, Kwak SH, Root KT, Fadil A, Nguyen A, Ladehoff L. Current approaches to craniopharyngioma management. Front Biosci (Landmark Ed). 2022. 27: 328

4. Dogra P, Bedatsova L, Van Gompel JJ, Giannini C, Donegan DM, Erickson D. Long-term outcomes in patients with adult-onset craniopharyngioma. Endocrine. 2022. 78: 123-34

5. Fan J, Liu Y, Pan J, Peng Y, Peng J, Bao Y. Endoscopic endonasal versus transcranial surgery for primary resection of craniopharyngiomas based on a new QST classification system: A comparative series of 315 patients. J Neurosurg. 2021. 135: 1298-309

6. Figueredo LF, Martínez AL, Suarez-Meade P, MarencoHillembrand L, Salazar AF, Pabon D. Current role of endoscopic endonasal approach for craniopharyngiomas: A 10-year systematic review and meta-analysis comparison with the open transcranial approach. Brain Sci. 2023. 13: 842

7. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003. 327: 557-60

8. Jeswani S, Nuño M, Wu A, Bonert V, Carmichael JD, Black KL. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: A single-institution study. J Neurosurg. 2016. 124: 627-38

9. Jimenez AE, Harrison Snyder M, Rabinovich EP, Malkawi D, Chakravarti S, Wei O. Comparison and evolution of transcranial versus endoscopic endonasal approaches for suprasellar Meningiomas: A systematic review. J Clin Neurosci. 2022. 99: 302-10

10. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World Neurosurg. 2012. 77: 329-41

11. Lei C, Chuzhong L, Chunhui L, Peng Z, Jiwei B, Xinsheng W. Approach selection and outcomes of craniopharyngioma resection: A single-institute study. Neurosurg Rev. 2021. 44: 1737-46

12. Li X, Wu W, Miao Q, He M, Zhang S, Zhang Z. Endocrine and metabolic outcomes after transcranial and endoscopic endonasal approaches for primary resection of craniopharyngiomas. World Neurosurg. 2019. 121: e8-14

13. Marx S, Tsavdaridou I, Paul S, Steveling A, Schirmer C, Eördögh M. Quality of life and olfactory function after suprasellar craniopharyngioma surgery-a single-center experience comparing transcranial and endoscopic endonasal approaches. Neurosurg Rev. 2021. 44: 1569-82

14. Morisako H, Goto T, Goto H, Bohoun CA, Tamrakar S, Ohata K. Aggressive surgery based on an anatomical subclassification of craniopharyngiomas. Neurosurg Focus. 2016. 41: E10

15. Nie C, Ye Y, Wu J, Zhao H, Jiang X, Wang H. Clinical outcomes of transcranial and endoscopic endonasal surgery for craniopharyngiomas: A single-institution experience. Front Oncol. 2022. 12: 755342

16. Ortiz Torres M, Shafiq I, Mesfin FB, editors. Craniopharyngioma. StatPearls. Treasure Island, FL: StatPearls Publishing; 2024. p.

17. Ozgural O, Kahilogullari G, Dogan I, Al-Beyati ES, Bozkurt M, Tetik B. Single-center surgical experience of the treatment of craniopharyngiomas with emphasis on the operative approach: Endoscopic endonasal and open microscopic transcranial approaches. J Craniofac Surg. 2018. 29: e572-8

18. Wannemuehler TJ, Rubel KE, Hendricks BK, Ting JY, Payner TD, Shah MV. Outcomes in transcranial microsurgery versus extended endoscopic endonasal approach for primary resection of adult craniopharyngiomas. Neurosurg Focus. 2016. 41: E6

19. Webb KL, Pruter WW, Hinkle ML, Walsh MT. Comparing surgical approaches for craniopharyngioma resection among adults and children: A meta-analysis and systematic review. World Neurosurg. 2023. 175: e876-96

20. Wu J, Pan C, Xie S, Tang B, Fu J, Wu X. A propensity-adjusted comparison of endoscopic endonasal surgery versus transcranial microsurgery for pediatric craniopharyngioma: A single-center study. J Neurosurg Pediatr. 2022. 29: 325-34

21. Yang C, Fan Y, Shen Z, Wang R, Bao X. Transsphenoidal versus transcranial approach for treatment of tuberculum sellae meningiomas: A systematic review and meta-analysis of comparative studies. Sci Rep. 2019. 9: 4882