Twenty years of endoscopic dacryocystorhinostomy: evolution of surgical technique and outcomes in a high-volume tertiary center

Purpose To report a 20-year experience with endonasal endoscopic dacryocystorhinostomy (EE-DCR) in a high-volume tertiary center for distal nasolacrimal duct obstruction (NLDO), and to evaluate temporal trends in surgical techniques and outcomes. Methods This retrospective, single-center study included consecutive adults who underwent EE-DCR between 2004 and 2024. Collected data included the surgical approach to the lacrimal sac (anterior vs. posterior), use of powered instrumentation, use of lacrimal transillumination, operative time, postoperative complications, and duration of bicanalicular stenting. Outcomes were assessed at 6 months (T1) and 12 months (T2). Surgical success was classified as anatomical, defined as patency on lacrimal irrigation, and functional, defined as resolution of epiphora. Sensitivity analyses were conducted for procedures performed after 2014 to limit learning-curve effects and reduce confounding. Results A total of 440 patients underwent 600 EE-DCRs (bilateral: 160/440, 36.4%). Over the study period, surgical practice shifted toward routine adoption of posterior access and powered instrumentation, whereas transillumination was progressively abandoned. Surgical failure significantly decreased in the second decade (<= 2014: T1 = 49/196, T2 = 55/196; >2014: T1 = 47/404, T2 = 51/353; p < 0.001). Mean operative time also declined (<= 2014: 33.33 +/- 16.19 min; >2014: 29.13 +/- 11.46 min; p = 0.019). Sensitivity analyses confirmed higher success rates with powered techniques and shorter procedures with posterior approaches, independent of confounders. Complication rates remained low and stable across decades. Conclusions Over 20 years, progressive refinement and standardization of EE-DCR resulted in improved surgical efficacy and shorter operative times without increased morbidity. In a large cohort with frequent concomitant sinonasal disease, EE-DCR proved to be safe, effective, and versatile.