Authors: Ankush Chandra; Harsh Wadhwa, BS; Jonathan Rick, BS; Ishan Kanungo, BS; Ivan El-Sayed, MD; Lewis Blevins, MD; Manish Aghi, MD, PhD (San Francisco, CA)

Introduction : Transsphenoidal surgery is the gold standard for treating most pituitary tumors and can be performed using microscopic (MTS) or endoscopic (ETS) approaches. We compared the economic burden and cost-effectiveness of the two approaches. Methods : Retrospective review of patients with pituitary adenomas (2007-2013) undergoing surgical resection at our institution and corresponding in-patient hospital cost. Results : Of 192 patients (median age=47.2; females=54.2%), ninety (46.8%) underwent ETS while 102 (53.2%) underwent MTS. All ETS were done with OHNS assistance while MTS were done solely by neurosurgeons. Temporal trends revealed a gradual increase in the number of endoscopic surgeries, with 4.43 more cases every year (R-square=0.88, p=0.002), while there was a gradual decline in the number of microscopic surgeries by 1.2 cases per year (R-square=0.35, p=0.032). Tumor characteristics were similar between both cohorts. The endoscopic cohort had lower total in-patient hospital costs compared to the microscopic cohort ($26,805 versus $37,371, p=0.001). Categorical analysis revealed that ETS patients had lower room/board ($7,328.48 versus $9,866.27, p=0.01) and operative costs ($7,035.27 versus $9,129.61, p=0.02) than MTS patients, while cost associated with labs, imaging, in-hospital pharmacy, pathology or any inpatient treatments were similar in both groups. Postoperatively, the endoscopic cohort had shorter hospital stays versus microscopic patients (2.1 days versus 2.8 days; p=0.02). Progression-free survival (4.6 years vs 4.1 years, p=0.04) and QALY scores (3.7 vs 3.21, p=0.026) were significantly better for endoscopic patients than microscopic patients. The incremental cost per QALY was $21,563 lower for the endoscopic approach. Conclusion : ETS was associated with lower hospital costs despite involving dual specialty co-surgeries, shorter stay in the hospital, and better QALY scores and progression-free survival. Multi-institutional validation of these findings could offer valuable information to centers considering transitioning to endoscopic approaches and could justify multidisciplinary co-surgeries to insurance payors who may inaccurately perceive these procedures to be costlier.