Despite ongoing advances in the pharmacological, radiotherapeutic and endoc
rine management of pituitary tumours, surgery remains the therapy of choice
for the large majority of these lesions. As surgical efficacy is now being
judged by more rigorous technical standards and by more stringent endocrin
e criteria than ever before, such scrutiny has only served to reinforce the
fundamental role of surgery in pituitary tumour management. With the reviv
al of the trans-sphenoidal approach, together with its ongoing technical ev
olution during the past three decades, pituitary tumours have emerged as em
inently treatable lesions, with transsphenoidal microsurgery affording long
-term, high-quality survival in many patients. Pituitary surgery is, howeve
r, not without limitation or liability. Even in experienced hands, endocrin
e and/or oncological remission is not uniformly achieved. Moreover, of thos
e patients in whom such 'cures' can be induced, the durability of the respo
nse is not absolute, as tumour recurrence will continue to threaten a small
but significant proportion of patients over time. Finally, and notwithstan
ding the fact that trans-sphenoidal surgery remains one of the safest proce
dures in contemporary, neurosurgical practice, complications fan occur, som
e of which can be associated with significant morbidity and, on rare occasi
ons, mortality. Clearly, there continue to be areas in need of improvement,
and it has been in response to these limitations of contemporary pituitary
surgery that neurosurgeons have sought to develop alternative strategies t
o improve surgical outcome. As a result, a variety of important innovations
have been introduced during recent years. Among others, the most important
and effective of these have been the application of neuronavigational tech
niques, trans-sphenoidal endoscopy and intraoperative MR resection control
to the standard trans-sphenoidal approach to pituitary tumours. Whereas som
e advances are conceptual and others are technical, all are helping to push
the limits of pituitary surgery to new frontiers of efficacy and safety. I
n this chapter, the current state of the art of pituitary surgery is review
ed along with those important new developments that, in the foreseeable fut
ure, hope to improve the quality of surgical care available to the pituitar
y tumour patient.