Table 1.

Summary of the pre-, peri- and postoperative management of NFPAs

Preoperative management
Endocrine assessment
∙ Rule out a hormone-producing adenoma clinically and biochemically
∙ HPA axis	- Morning serum cortisol; dynamic testing if needed - Introduce GC replacement if SAI is confirmed
∙ Thyroid	- Serum TSH and free T4 - Introduce L-thyroxine in severe CH
∙ HPG axis	- Evaluate hypogonadism clinically and biochemically - Sex hormone replacement is usually not indicated preoperatively
∙ Somatotropic axis	- Diagnosis and/or treatment for GHD is not recommended preoperatively
Radiological assessment
∙ MRI evaluating the relationship to the chiasma and optic nerve, and grading of extrasellar extension using the Knosp scale
Ophthalmologic assessment
- Visual field, visual acuity, and eye movement
Perioperative and early postoperative management
∙ GC therapy	- Administrate stress doses of GCs in patients with confirmed and suspicion of SAI - Monitor morning serum cortisol regularly in patients without SAI who do not receive GCs perioperatively - Introduce GCs if cortisol deficiency is detected
∙ Fluid balance	- Monitor urine volume and serum sodium regularly to detect hyponatremia and/or DI
Postoperative management
Endocrine assessment
∙ HPA axis	- Re-evaluation of HPA axis with morning serum cortisol and a dynamic testing, if needed, after 6–12 weeks
∙ Thyroid	- Morning serum TSH and free T4 - In case of CH, introduce L-thyroxine only after HPA axis has been assessed and cortisol deficiency corrected
∙ HPG axis	- Clinical and biochemical evaluation of hypogonadism - Introduce sex hormone replacement in pre-menopausal women, if needed - Introduce testosterone replacement in men, if needed
∙ Somatotropic axis	- Assess GHD after 6–12 months and only after any other hormone deficiency is adequately replaced - Introduce GH replacement therapy if GHD is confirmed
Radiological assessment
∙ Perform the first MRI 3–6 months following surgery   ∙ Subsequent follow-up is individualized based on MRI findings and histopathological diagnosis
Ophthalmologic assessment
∙ First examination within 3 months   ∙ Patients with postoperative visual defects need further follow-up

CH central hypothyroidism, DI diabetes insipidus, GC glucocorticoid, GH growth hormone, GHD growth hormone deficiency, HPA hypothalamus–pituitary–adrenal, HPG hypothalamus-pituitary–gonadal, MRI magnetic resonance imaging, NFPA non-functioning pituitary adenoma, SAI secondary adrenal insufficiency, TSH thyroid-stimulating hormone