Perspectives on endoscopic transsphenoidal surgery

Sellar tumors are most commonly approached through the transsphenoidal corridor, and tumor resection is most often performed using the operating microscope. More recently the endoscope has been introduced for use either as an adjunct to or in lieu of the microscope. Both the microscopic and endoscopic transsphenoidal approaches to sellar tumors allow safe and effective tumor resection. The authors describe their current endoscopic technique and elucidate the advantages and disadvantages of the pure endoscopic adenomectomy compared with the standard microscopic approach.

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Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma

Journal of Neurosurgery ◽

10.3171/2015.4.jns15102 ◽

2016 ◽

Vol 124 (3) ◽

pp. 596-604 ◽

Cited By ~ 31

Author(s):

Hasan A. Zaidi ◽

Al-Wala Awad ◽

Michael A. Bohl ◽

Kristina Chapple ◽

Laura Knecht ◽

...

Keyword(s):

Pituitary Adenoma ◽

Endoscopic Surgery ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Tumor Resection ◽

Endoscopic Technique ◽

Endoscopic Transsphenoidal Surgery ◽

Experienced Surgeon ◽

Surgery Technique ◽

Surgeon Experience

OBJECT The comparative efficacy of microscopic and fully endoscopic transsphenoidal surgery for pituitary adenomas has not been well studied despite the adoption of fully endoscopic surgery by many pituitary centers. The influence of surgeon experience has also not been examined in this setting. The authors therefore compared the extent of tumor resection (EOR) and the endocrine outcomes of 1 very experienced surgeon performing a microscopic transsphenoidal surgery technique with those of a less experienced surgeon using a fully endoscopic transsphenoidal surgery technique for resection of nonfunctioning pituitary adenomas in a concurrent series of patients. METHODS Post hoc analysis was conducted of a cohort of adult patients prospectively enrolled in a pituitary adenoma quality-of-life study between October 2011 and June 2014. Patients were followed up for 6 months after surgery. Patients were treated either by a less experienced surgeon (100 independent cases) who practices fully endoscopic surgery exclusively or by a very experienced surgeon (1800 independent cases) who practices microscopic surgery exclusively. Patient demographic characteristics, tumor characteristics, hypopituitarism, complications, and length of hospital stay were analyzed. Tumor volumes and EOR were determined by formal volumetric analysis involving manual segmentation of MR images performed before surgery and within 6 months after surgery. Logistic regression analysis was used to determine predictors of EOR. RESULTS Fifty-five patients underwent fully endoscopic transsphenoidal surgery, and 80 patients underwent fully microscopic transsphenoidal surgery. The baseline characteristics of the 2 treatment groups were well matched. EOR was similar between the endoscopic and microscopic groups, respectively, as estimated by gross-total resection rate (78.2% vs 81.3%, p = 0.67), percentage of tumor resected (99.2% vs 98.7%, p = 0.42), and volume of residual tumor (0.12 cm3 vs 0.20 cm3, p = 0.41). Multivariate modeling suggested that preoperative tumor volume was the most important predictor of EOR (p = 0.001). No difference was found in the development of anterior gland dysfunction (p > 0.14), but there was a higher incidence of permanent posterior gland dysfunction in the microscopic group (p = 0.04). Combined rates of major complications and unplanned readmissions were lower in the endoscopic group (p = 0.02), but individual complications were not significantly different. CONCLUSIONS A less experienced surgeon using a fully endoscopic technique was able to achieve outcomes similar to those of a very experienced surgeon using a microscopic technique in a cohort of patients with nonfunctioning tumors smaller than 60 cm3. The study raises the provocative notion that certain advantages afforded by the fully endoscopic technique may impact the learning curve in pituitary surgery for nonfunctioning adenomas.

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Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study

Journal of Neurosurgery ◽

10.3171/2018.11.jns181238 ◽

2020 ◽

Vol 132 (4) ◽

pp. 1043-1053 ◽

Cited By ~ 6

Author(s):

Andrew S. Little ◽

Daniel F. Kelly ◽

William L. White ◽

Paul A. Gardner ◽

Juan C. Fernandez-Miranda ◽

...

Keyword(s):

Endoscopic Surgery ◽

Surgical Outcomes ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Tumor Resection ◽

Extent Of Resection ◽

Endoscopic Technique ◽

Controlled Study ◽

Nonfunctioning Pituitary Adenomas ◽

Microscopic Surgery

OBJECTIVEMany surgeons have adopted fully endoscopic over microscopic transsphenoidal surgery for nonfunctioning pituitary tumors, although no high-quality evidence demonstrates superior patient outcomes with endoscopic surgery. The goal of this analysis was to compare these techniques in a prospective multicenter controlled study.METHODSExtent of tumor resection was compared after endoscopic or microscopic transsphenoidal surgery in adults with nonfunctioning adenomas. The primary end point was gross-total tumor resection determined by postoperative MRI. Secondary end points included volumetric extent of tumor resection, pituitary hormone outcomes, and standard quality measures.RESULTSSeven pituitary centers and 15 surgeons participated in the study. Of the 530 patients screened, 260 were enrolled (82 who underwent microscopic procedures, 177 who underwent endoscopic procedures, and 1 who cancelled surgery) between February 2015 and June 2017. Surgeons who used the microscopic technique were more experienced than the surgeons who used the endoscopic technique in terms of years in practice and number of transsphenoidal surgeries performed (p < 0.001). Gross-total resection was achieved in 80.0% (60/75) of microscopic surgery patients and 83.7% (139/166) of endoscopic surgery patients (p = 0.47, OR 0.8, 95% CI 0.4–1.6). Volumetric extent of resection, length of stay, surgery-related deaths, and unplanned readmission rates were similar between groups (p > 0.2). New hormone deficiency was present at 6 months in 28.4% (19/67) of the microscopic surgery patients and 9.7% (14/145) of the endoscopic surgery patients (p < 0.001, OR 3.7, 95% CI 1.7–7.7). Microscopic surgery cases were significantly shorter in duration than endoscopic surgery cases (p < 0.001).CONCLUSIONSExperienced surgeons who performed microscopic surgery and less experienced surgeons who performed endoscopic surgery achieved similar extents of tumor resection and quality outcomes in patients with nonfunctioning pituitary adenomas. The endoscopic technique may be associated with lower rates of postoperative pituitary gland dysfunction. This study generally supports the transition to endoscopic pituitary surgery when the procedure is performed by proficient surgeons, although both techniques yield overall acceptable surgical outcomes.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: prospective cohort trial; evidence: class III.Clinical trial registration no.: NCT02357498 (clinicaltrials.gov)

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Early outcomes of endoscopic transsphenoidal surgery for adult craniopharyngiomas

Neurosurgical FOCUS ◽

10.3171/2010.1.focus09319 ◽

2010 ◽

Vol 28 (4) ◽

pp. E9 ◽

Cited By ~ 66

Author(s):

John A. Jane ◽

Erin Kiehna ◽

Spencer C. Payne ◽

Stephen V. Early ◽

Edward R. Laws

Keyword(s):

Mr Imaging ◽

Transsphenoidal Surgery ◽

Tumor Resection ◽

Imaging Study ◽

High Rate ◽

Transsphenoidal Approach ◽

Gross Total Resection ◽

Csf Leak ◽

Total Resection ◽

Endoscopic Transsphenoidal Surgery

Object Although the transsphenoidal approach for subdiaphragmatic craniopharyngiomas has been performed for many years, there are few reports describing the role of the endoscopic transsphenoidal technique for suprasellar craniopharyngiomas. The purpose of this study was to report the outcomes of the endoscopic transsphenoidal approach for adults with craniopharyngiomas in whom the goal was gross-total resection. Methods Twelve patients were identified who were older than 18 years at the time of their pure endoscopic transsphenoidal surgery. Their medical records and imaging studies were retrospectively reviewed. Results Gross-total resection was achieved in 42% of cases when assessed by intraoperative impression alone and in 75% when assessed by the first postoperative MR imaging study. However, 83% of patients achieved at least a 95% resection when assessed by both intraoperative impression and the first postoperative MR imaging study. Permanent diabetes insipidus occurred postoperatively in 44% of patients. Six (67%) of 9 patients who had a functioning hypothalamic-pituitary axis preoperatively developed panhypopituitarism after surgery. Visual improvement or normalization occurred in 78% of patients with preoperative visual deficits. Although no patient experienced a postoperative CSF leak, 1 patient was treated for meningitis. Conclusions The authors have achieved a high rate of radical resection and symptomatic improvement with the endoscopic transsphenoidal technique for both subdiaphragmatic (sellar/suprasellar) and supradiaphragmatic (suprasellar) craniopharyngiomas. However, this is also associated with a high incidence of new endocrinopathy. Endoscopic assessment of tumor resection may be more sensitive for residual tumor than the first postoperative MR imaging study.

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Outcomes of Surgically Treated Giant Pituitary Tumours

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100013950 ◽

2012 ◽

Vol 39 (4) ◽

pp. 446-457 ◽

Cited By ~ 36

Author(s):

Michael D. Cusimano ◽

Peter Kan ◽

Farshad Nassiri ◽

Jennifer Anderson ◽

Jeannette Goguen ◽

...

Keyword(s):

Clinical Outcomes ◽

Surgical Complications ◽

Transsphenoidal Surgery ◽

Tumor Volume ◽

Tumor Resection ◽

Pituitary Tumours ◽

Median Length ◽

Recurrence Rates ◽

Endoscopic Transsphenoidal Surgery

Objective:To evaluate the outcomes of patients with giant pituitary tumours (GPTs) who underwent a purely binasal endoscopic transsphenoidal surgery (BETS) and compare their outcomes with those achieved through craniotomy and microscopic transsphenoidal surgery (MTS).Methods:Seventy-two consecutive patients with GPTs (greater than 10 cm3 in volume) who were treated surgically with BETS, craniotomy, or MTS from October 1994 to July 2009 were reviewed for clinical outcomes, degree of tumor resection, recurrence rates, and surgical complications.Results:The BETS group had significantly better mean reduction of tumor volume (91%) than the craniotomy (63%, p = 0.001), and the MTS (63%, p = 0.010) groups. Gross total resection rates were also higher for BETS patients than for craniotomy patients (p = 0.010). Improvements in vision and headaches were noted in 96% and 100% of patients in the BETS group, respectively; these rates were similar to those in the craniotomy and MTS groups. Of the four patients with hormone-secreting tumours in the BETS group, three remained in remission. The median length-of-stay (four days) for the BETS group was shorter (p = 0.010), and surgical complications were less frequent (p = 0.037) and less severe compared to the craniotomy group. There were no differences in the recurrence rates: 79% percent of patients in the BETS group, 69% in the craniotomy group, and 79% in the MTS group were recurrence free at last follow-up (p = 0.829).Conclusions:Treatment of GPT with BETS offers excellent oncologic and clinical outcomes and can frequently obviate the need for craniotomy in these patients.

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