Objective To explore the microsurgical treatment for large pituitary adenomas. Methods Surgical approaches were determined according to sites of tumor, texture, hormone level, and T 2 signals of MRI. Transpterional sinus approach was adopted in 82 cases, transinferior frontal approach in 22 ones, transsphenoidal sinus approach in 6 ones and subfrontal transsphenoidal sinus approach in 3 ones. All cases underwent radiotherapy after operation. Results Total resection of tumors was obtained in 102 cases (90 3%), and subtotal resection of tumors in 11 cases (9 7%) under microscope. 2 cases died after operation (1 8%). Postoperative vision and visual field were improved in 98 cases (86 7%) and no change in 15 cases (13 3%). 6 cases relapsed in 5 years postoperatively(6 3%). Conclusions Selecting different surgical approaches based on features of tumor by microsurgery combined with comprehensive therapy are key factors to improve total resection rate and decrease mortality and recurrence rate for large pituitary adenomas.