BACKGROUND: Craniopharyngioma is a benign, locally invasive tumor of the sellar-suprasellar region. Surgery can be curative but may require sacrifice of the pituitary stalk, which often leads to hypopituitarism. The risk/benefit of this maneuver is not well understood. METHODS: We performed a systematic English literature search on craniopharyngioma surgery with data on stalk preservation. We used meta-analysis for odds ratio in R software (R Foundation for Statistical Computing, Vienna, Austria). We have also used available raw data for recurrence risk using the Kaplan-Meier curve. RESULTS: Significantly lower recurrence risk was noted in patients in whom the stalk was sacrificed (11% vs. 23%, P = 0.003). This held true in patients after endoscopic endonasal approach (EEA) regardless of the extent of resection (P = 0.001) and in patients with gross total resection after EEA (P = 0.032). Survival analysis confirmed lower recurrence risk in adults with gross total resection after EEA and stalk sacrifice (P = 0.007, log-rank test). In patients with stalk sacrifice, the risk of panhypopituitarism was more than doubled (85% vs. 40%
P <
0.001), as was the risk of somatotrope insufficiency (89% vs. 32%
P <
0.001). Additionally, there was an approximate 30% increase in the risk of hypocortisolemia (94% vs. 62%
P <
0.001), hypothyroidism (96% vs. 59%
P <
0.001), gonadotrope insufficiency (92% vs. 59%
P <
0.001), and diabetes insipidus (80% vs. 55%
P <
0.001). The risk of weight gain was also significantly increased (30% vs. 16%
P = 0.025). CONCLUSIONS: Our review indicates that stalk sacrifice is often required to achieve a durable cure in patients with craniopharyngiomas. While stalk sacrifice increases the risk of postoperative endocrinopathy, even if the stalk is preserved, many patients will still become hypopituitary.