Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures

Abstract

IntroductionEndoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA) has been a recent shift from the traditional microscopic technique. Although some literature demonstrated superiority of ETSS over the microscopic method and some evaluated mono- vs. binostril access within the ETSS, none had explored the potential influence of dedicated instrument, as this procedure had evolved, on patients’ outcomes when compared to traditional microscopic tools.ObjectiveTo investigate our own clinical and radiographic outcomes of ETSS for PA with its technical evolution over time as well as a significance of, having vs. lacking, the special endoscopic tools.MethodsIncluded patients underwent ETSS for PA performed by the first author (AH). Prospectively recorded patients’ data concerning pre-, intra- and postoperative clinical and radiographic assessments were subject to analysis. The three groups of differently evolving ETSS techniques, beginning with mononostril (MN) to binostril ETSS with standard microsurgical instruments (BN1) and, lastly, binostril ETSS with specially-designed endoscopic tools (BN2), were examined for their impact on the intra- and, short- and long-term, postoperative results. Also, the survival after ETSS for PA, as defined by the need for reintervention in each technical group, was appraised.ResultsFrom January 2006 to 2012, there were 47, 101 and 72 ETSS, from 183 patients, in the MN, BN1 and BN2 cohorts, respectively. Significant preoperative findings were greater proportion of patients with prior surgery (p=0.01) and tumors with parasellar extension (p=0.02) in the binostril (BN1&2) than the MN group. Substantially shorter operative time and less amount of blood loss were evident as our technique had evolved (p<0.001). Despite higher incidence, and more advanced grades, of cerebrospinal fluid leakage in the binostril groups (p < 0.001), the requirement for post-ETSS surgical repair was less than the mononostril cohort (p=0.04). At six-month follow-up (n=214), quantitative radiographic outcome analysis was markedly superior in BN2. Consequently, long-term result was better in this latest technical group. Important negative risk factors, from multivariate Cox regression analysis, were prior surgery, Knosp grade, and firm tumor while BN1, BN2 and percentages of anteroposterior dimension PA removal had positive effect on longer survival.ConclusionThe evolution of technique for ETSS for PA from MN to BN2 has shown its efficacy by improving intra- and postoperative outcomes in our study cohorts. Based on our results, not only that a neurosurgeon, wishing to start performing ETSS, should enroll in a formal fellowship training but he/she should also utilize advanced endoscopic tools, as we have proved its superior results in dealing with PA.

Cerebrospinal Fluid Leak after Transsphenoidal Surgery: A Systematic Review and Meta-analysis

“…Although, self-limiting CSF rhinorrhea is very rare, not all patients require intervention by reoperation, which may result in lower reporting of CSF leak in studies incorporating the need for surgical repair in their definition. 37 38…”

Outcomes of the endoscopic transsphenoidal surgery for resection of pituitary adenomas utilizing extracapsular dissection technique with a cotton swab

“…Surgical technique, for the nasal, sphenoidal, and sellar phases, was similar to the previously narrated steps in our earlier publication. [2] Switching from curettage for PA removal, the senior author (AH) utilized cotton swab since 2014, as described by Prevedello et al ,[1] for extracapsular dissection [Figure 1]. The intraoperative data, including suspected or definite residual PA, and complication(s) were recorded.…”

“…For cerebrospinal fluid (CSF) leakage, grading was based on Esposito et al [3] The method for sellar defect repair, depending on CSF leak grade, was similar to our previous literature. [2] Although the cotton swab technique was undertaken in all of the cases, patients who had internal debulking only without circumferential pseudocapsule resection, as their intended surgical goal, were excluded from our analysis.…”

Comparison of serum dynamic thiol/disulphide homeostasis and nitric oxide levels of total intravenous vs inhaled anaesthesia in endoscopic transsphenoidal pituitary surgery

“…Pituitary tumours involve about 10% of diagnosed neoplasms of the brain, 1 and endoscopic transsphenoidal pituitary surgery (TPS) is a common approach in such cases as a minimally invasive procedure 2,3 . TPS is traditionally performed under general anaesthesia.…”

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Pituitary tumours involve about 10% of diagnosed neoplasms of the brain, 1 and endoscopic transsphenoidal pituitary surgery (TPS) is a common approach in such cases as a minimally invasive procedure. 2,3 TPS is traditionally performed under general anaesthesia. The major challenge of the anaesthesia team during TPS is the maintenance of intraoperative haemodynamic stability while maintaining controlled hypotension to decrease bleeding.

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