Surgery is generally used as second-line treatment in prolactinomas. For microprolactinomas, it may be indicated in cases of resistance or intolerance to dopamine agonists or where patients prefer definitive cure to lifelong drug treatment. In highly trained hands, selective adenomectomy results in normalization of prolactin levels in 75-90% of cases with little morbidity and no mortality. However, subsequent relapse is possible in up to 20% of cases. In macroprolactinoma, a definitive cure is unlikely due to the frequency of invasive tumor extension. A transsphenoidal or, less frequently, a transfrontal surgical approach is necessary in patients resistant to or intolerant of medical treatment, and also in rare cases such as pituitary apoplexy or cerebrospinal fluid rhinorrhea.