Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach

Abstract

<jats:p>Resection remains the mainstay of treatment for craniopharyngiomas with the goal of radical resection, if safely possible, to minimize the rate of recurrence. Endoscopic endonasal and microscopic transcranial surgical approaches have both become standard methods for the treatment for craniopharyngiomas. However, the approach selection paradigm for craniopharyngiomas is still a point of discussion. Choosing the optimal surgical approach can play a significant role in maximizing the extent of resection and surgical outcome while minimizing the risks of potential complications. Craniopharyngiomas can present with a variety of different sizes, locations, and tumor consistencies, and each individual tumor has distinct features that favor one specific approach over another. The authors review standard cranial base techniques applied to craniopharyngioma surgery, using both the endoscopic endonasal approach and traditional open microsurgical approaches, and analyze factors involved in approach selection. They discuss their philosophy of approach selection based on the location and extent of the tumor on preoperative imaging as well as the advantages and limitations of each surgical corridor, and they describe the operative nuances of each technique, using a personalized, tailored approach to the individual patient with illustrative cases and videos.</jats:p>

Endoscopic and Microscopic Transsphenoidal Surgery of Craniopharyngiomas: A Systematic Review of Surgical Outcomes Over Two Decades

“…Accordingly, the main goal of the treatment of CRs is to achieve a maximal safe resection with preservation of neurologic functions, rather than aggressive and radical tumor excision. 11,12…”

Pediatric Craniopharyngiomas: A Primer for the Skull Base Surgeon

“…[60][61][62] Given these anatomic limitations, prior to the development of the endoscopic endonasal approach (EEA) and its extended variants, microsurgical transsphenoidal resection was largely reserved for intrasellar craniopharyngiomas, or tumors with minimal, midline extension beyond the subdiaphragmatic space. [63][64][65] The implications of this fundamental distinction in pediatric patients selected for transsphenoidal versus transcranial craniopharyngioma resections were realized in the meta-analysis performed by Elliott et al . 66 Perhaps unsurprisingly, given that the vast majority of the transsphenoidal operations included in their meta-analysis were for small, intrasellar tumors, their chief conclusion was that significant selection bias was present between the cohorts, and that a valid comparison could not be performed.…”

“…In spite of 75% of tumors having supradiaphragmatic extension, GTR was achieved in 70% overall (92% in primary resections; 38% in revision operations), and overall rates of worsened anterior pituitary function were 50%-comparable to preceding outcomes observed after transcranial resections of large pediatric craniopharyngiomas. 65,66,76 Perhaps the most important advantage in considering an EEA for craniopharyngioma resection is clear visualization of the retrochiasmatic space and inferior hypothalamus-both of which are often involved with tumor, risk significant morbidity, and are often inadequately accessed via anterior transcranial approaches. 65,77,78 By turn, tumors with extensive superior or lateral extension into the interhemispheric or Sylvian fissures are poorly managed via EEA, and require either a transcranial or combined approach, based on their overall architecture.…”

“…65,66,76 Perhaps the most important advantage in considering an EEA for craniopharyngioma resection is clear visualization of the retrochiasmatic space and inferior hypothalamus-both of which are often involved with tumor, risk significant morbidity, and are often inadequately accessed via anterior transcranial approaches. 65,77,78 By turn, tumors with extensive superior or lateral extension into the interhemispheric or Sylvian fissures are poorly managed via EEA, and require either a transcranial or combined approach, based on their overall architecture. 65 Interestingly, several authors have also demonstrated that a pronounced learning curve exists in the adoption of EEA techniques, appreciable at both the level of individual surgeons and the skull base community at large.…”

“…65,77,78 By turn, tumors with extensive superior or lateral extension into the interhemispheric or Sylvian fissures are poorly managed via EEA, and require either a transcranial or combined approach, based on their overall architecture. 65 Interestingly, several authors have also demonstrated that a pronounced learning curve exists in the adoption of EEA techniques, appreciable at both the level of individual surgeons and the skull base community at large. 79,80 CSF leak remains the most pronounced disadvantage of EEA when compared with transcranial approaches; however, early data likely overestimated this risk, as reconstructive techniques centered around vascularized, pedicled nasoseptal flaps and multilayer repairs were not yet standard-of-care, and in experienced hands the actual risk is more accurately estimated at 1% to 5%.…”