Transsphenoidal pituitary surgery via the endoscopic technique: results in 35 consecutive patients with Cushing’s disease

Abstract

Objective and design: The endoscopic technique has been recently introduced in the field of transsphenoidal pituitary surgery. This technique allows inspection of sellar, supra-and parasellar structures and removal of the tumor under direct visualization, is minimally traumatic and permits easier reoperations. This is the first report on the results of endoscopic surgery for patients with Cushing's disease. Our aim was to retrospectively analyze the results of pituitary surgery in 35 consecutive patients with Cushing's disease operated in our hospital after the introduction of the endoscopic technique (1998 -2004). Methods: Remission was defined as suppression of plasma cortisol (# 50 nmol/L) after 1 mg dexamethasone overnight determined in the first 3 months after surgery and disappearance of clinical signs and symptoms of hypercortisolism. The patients were followed for an average of 27 months (range 4 to 81 months, median 20 months). Results: Pituitary MRI showed a macroadenoma in 6 patients, a microadenoma in 17 patients and no adenoma in 12 patients. After the initial surgery 27 patients (77%) were in remission. None of the patients had a relapse during follow-up. In the remaining 8 patients hypercortisolemia persisted after surgery. Three of them had a second endoscopic pituitary surgery resulting in remission in two patients. In one patient a second endoscopic pituitary surgery will soon follow. The remaining four patients were treated with radiotherapy postoperatively. Two of them were at the time of data collection in remission. One patient from the remission group had a serious epistaxis and three patients had cerebrospinal fluid leakage, one requiring an external lumbar drain, shortly after surgery. No complications were recorded in the failure group. Postoperatively 34% of all patients required substitution with levothyroxine, 40% required substitution with glucocorticoids, 17% received estrogens or testosterone and 6% still required desmopressin. Conclusions: Endoscopic transsphenoidal pituitary surgery resulted in our series of patients with Cushings disease in an excellent postoperative remission rate. A randomized clinical trial, comparing endoscopic and conventional pituitary surgery in patients with Cushings disease, is needed to determine the pros and cons of both techniques.European Journal of Endocrinology 154 675-684

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

“…Vascular complications of endoscopic TS and microscopic TS are identical. 38 We previously reported a complication rate of 29% in our study on results of primary endoscopic TS in patients with CD, 3 which is similar to the complication rates reported in studies of primary microscopic TS in patients with CD. The studies on repeated TS in patients with persistent or recurrent CD report complication rates varying between 0% and 91%.…”

“…8 Overall, the remission rates reported after second TS in persistent or recurrent CD seem to be slightly lower than the remission rates reported after first TS which vary from 50% to 90%, but are mostly 70-85%. [3][4][5][6][7][8][9] Nevertheless, the majority of the patients with persistent or recurrent CD can still instantly be cured by repeated TS, and the remission rate we achieved via the endoscopic technique seems to be at least as good as the remission rate achieved by repeated TS via the conventional microscopic technique.…”

“…Previously, we reported a CSF leakage rate of 8·5% in primary endoscopic TS in patients with CD operated on by the same neurosurgeons that operated the patients in this study. 3 When comparing rates of CSF leakage it is important to note that most studies only report on the rates of postoperative CSF leakage. The rate of postoperative CSF leakage is lower (1-4% during first TS) than the rate of intra-operative CSF leakage (9-25% during first TS).…”

“…The rate of hormonal deficiencies was 48% in our earlier study on results of first endoscopic TS in patients with CD. 3 The higher rates of hypopituitarism after repeated TS compared to after the first TS can be expected because additional pituitary tissue is removed. Even so, the risk of hypopituitarism after second TS seems to be lower than reported rates of hypopituitarism several years after radiotherapy.…”

“…However, CD persists in the remaining patients, and 5-25% of the patients who are initially in remission develop a recurrence. [3][4][5][6][7][8] Treatment options for persistent or recurrent CD include radiation therapy, bilateral adrenalectomy, medical therapy and repeated TS. Thus far, no consensus exists on which therapy is preferable.…”