OBJECTIVES: To analyze and summarize the clinical characteristics, surgical outcomes, and prognosis of elderly adults with pituitary adenomas (PAs). DESIGN: Retrospective cohort study. SETTING: Tongji Hospital. PARTICIPANTS: Individuals who underwent transsphenoidal surgery for PAs between 2009 and 2012 (N = 1,104). MEASUREMENTS: Participants were divided into two age groups (>= 65 and < 65), and their clinical characteristics, surgical complications, surgical outcomes, and follow-up data were analyzed and compared. RESULTS: The older group had longer duration of symptoms. The most common symptom were mass effects (98.4%) in the older group and hormone-secreting effects (55.2%) in the younger group. The incidence of pituitary apoplexy (P = .03), incidentaloma (P = .03) and misdiagnosis at first visit (P < .001) were higher in the older group. Nonfunctioning PAs (P < .001) and giant adenomas (P = .04) were more common in the elderly group than in the younger group. There were no significant differences in the incidence of postoperative diabetes insipidus, cerebrospinal fluid (CSF) leak, regrowth, visual outcome, or permanent hypopituitarism between the groups (P > .05). The incidence of severe systemic complications was greater in the older group (3/69 vs 3/1,035, relative risk = 15.00, 95% confidence interval = 3.08-72.94, P = .004), and all three cases in the older group occurred after emergency surgery. The incidence of hypopituitarism before surgery and 3 days after surgery was higher in the elderly group (P < .05). Older participants tended to have more difficulty recovering from preoperative hypopituitarism (P = .02). CONCLUSION: Avoiding misdiagnosis and emergency surgery is critical for frail elderly adults with multiple comorbidities. With early active management, sufficient preoperative preparation, and multidisciplinary collaboration, the long-term outcomes and prognosis of elderly adults with PAs are comparable with those of younger adults.