Effect of pituitary stalk preservation in endoscopic endonasal surgery for suprasellar craniopharyngiomas: a tertiary center experience

OBJECTIVE Craniopharyngioma is increasingly recognized as a chronic morbidity-driven disease in which hypothalamic and pituitary dysfunction often outweigh purely oncological endpoints. The advent of extended endoscopic endonasal approaches (EEAs) has improved visualization of the infundibulum, yet the optimal management of the pituitary stalk remains controversial. The aim of this study was to evaluate the impact of pituitary stalk preservation versus transection on endocrine, visual, surgical, and early oncological outcomes in patients with suprasellar craniopharyngiomas treated via an extended EEA. METHODS This retrospective analysis reviewed consecutive patients with suprasellar craniopharyngiomas operated on via an extended EEA through the infrachiasmatic corridor between January 2024 and May 2025 in a high-volume tertiary skull base center. Tumor topography was classified according to Kassam and Tang systems, and the intraoperative strategy was to preserve the pituitary stalk whenever an oncologically acceptable dissection plane could be identified. Demographic data, visual outcomes, extent of resection, endocrine status (corticotropic, thyrotropic, gonadotropic axes, and diabetes insipidus), and recurrence were compared between the stalk-preservation and stalk-transection groups using the t-test and chi-square test. RESULTS Thirty-three patients (17 male, mean age 33.45 years) were included in this study, with a mean follow-up duration of 12.1 ± 4.7 months. Overall, gross-total resection was achieved in 20 patients (60.6%) and recurrence occurred in 2 patients (6.1%). Both recurrence events were observed after stalk transection (2/11, 18.2%), with no recurrences after stalk preservation (0/22) during the available follow-up. Stalk transection did not significantly increase the likelihood of gross-total resection (p = 0.456). New-onset adrenal insufficiency (30.3%), hypogonadism (15.2%), and permanent diabetes insipidus (39.4%) were strongly associated with stalk transection (p = 0.006, p = 0.033, and p < 0.001, respectively). Ophthalmological evaluation revealed visual impairment in 19 patients (57.6%); postoperative assessment demonstrated visual improvement in 11 patients (57.8%), while vision remained unchanged in 8 patients. CONCLUSIONS In this tertiary center series of suprasellar craniopharyngiomas treated via an extended EEA, pituitary stalk transection markedly increased permanent diabetes insipidus and anterior pituitary deficits without improving the extent of resection or early tumor control during a mean follow-up of 12 months. While true stalk preservation is often unfeasible in transinfundibular lesions, these findings support infundibulum-preserving surgery as a key strategy in pre- and retroinfundibular tumors to optimize endocrine outcomes and quality of life, and it should be considered the preferred goal whenever oncologically safe.