A Narrative Review of Surgery for Prolactinomas: Considerations and Controversies

For several decades, dopamine agonist therapy has been the mainstay of treatment for prolactinomas, with surgery generally considered a second line for cases failing medical therapy due to intolerance or resistance. There is increasing recognition of the burden of long-term DA therapy; many patients experience debilitating side effects, and emerging evidence demonstrates that the prevalence of impulse control disorders has been vastly underreported. Long-term DA therapy is associated with significant costs to patients and healthcare systems, which is projected to exceed that of surgery in many circumstances. Recent advancements in surgical approaches, including endoscopic transsphenoidal surgery, have led to improved surgical outcomes (82-100% remission rates; serious complication rates < 2%), prompting a reappraisal of the role of surgery for prolactinoma. Favourable surgical outcomes have been observed in both remission and complication rates for microprolactinomas and well-circumscribed macroprolactinomas, leading to consideration of surgery as an earlier, or first-line, option in the treatment paradigm. Potential advantages of surgical management should be weighed against institutional case volume and expertise, the risk of perioperative complications, and the need for adjuvant medical therapy post-operatively. Ultimately, patients and care-providers should engage in shared decision-making following informed discussion about the risks and benefits of both medical and surgical approaches.