Outcomes and Complications of Aggressive Resection Strategy for Pituitary Adenomas in Knosp Grade 4 With Transsphenoidal Endoscopy

Surgery for pituitary adenomas (PAs) with cavernous sinus (CS) invasion in Knosp grade 4 is a great challenge and whether to adopt a conservative or aggressive surgical strategy is controversial. The aim of this study is to provide the outcomes and complications of an aggressive resection strategy for Knosp grade 4 PAs with transsphenoidal endoscopic surgery. Outcomes and complications were retrospectively analyzed in 102 patients with Knosp grade 4 PAs. Among them, primary PAs were seen in 60 patients and recurrent PAs were seen in 42 cases. Gross total resection (GTR) of the entire tumor was achieved in 72 cases (70.6%), subtotal tumor resection (STR) in 18 cases (17.6%), and partial tumor resection (PTR) in 12 cases (11.8%). Additionally, GTR of the tumor within the CS was achieved in 82 patients (80.4%), STR in 17 patients (16.7%), and PTR in 3 patients (2.9%). Statistical analyses showed that both recurrent tumors and firm consistency tumors were adverse factors for complete resection (P<0.05). Patients with GTR of the entire tumor were more likely to have favorable endocrine and visual outcomes than those with incomplete resection (P<0.05). Overall, the most common surgical complication was new cranial nerve palsy (n=7, 6.8%). The incidence of internal carotid artery (ICA) injury and postoperative cerebrospinal fluid (CSF) leakage was 2.0% (n=2) and 5.9% (n=6), respectively. Six patients (5.9%) experienced tumor recurrence postoperatively. For experienced neuroendoscopists, an aggressive tumor resection strategy via transsphenoidal endoscopic surgery may be an effective and safe option for Knosp grade 4 PAs.

Microvascular doppler associated with neuronavigation to intraoperative identification and location of internal carotid artery in transsphenoidal endoscopic pituitary macroadenomas surgery

Context: Enhancements in pulsed doppler techniques have made easier to apply those techniques not only to diagnose brain vascular diseases but also in brain surgery, especially to disclose arteries close to tumors and avoid their manipulation. The aim of this paper is to describe the technique of microvascular doppler associated with neuronavigation in transsphenoidal endoscopic surgery to remove pituitary macroadenomas in three patients. Material And Methods: A sterile 2mm 16-MHz probe was used inside a long curved canula of 17 cm length, attached with a neuronavigation reference. The neuronavigation mapping was done with MRI and angiotomography, which took place 24 hours before the procedure. Results: Intraoperatively, the doppler identified arterial flow compatible with the anatomical localization of the cavernous portion of internal carotid artery, as shown by the neuronavigation system, and this place was avoided during surgery, allowing manipulation of the tumor without risk of damage to the internal carotid artery. The results after surgery were total removal of the tumor in all three cases. No postoperative vascular complications were present. Conclusion: The method with microvascular doppler associated with neuronavigation was essential to the intraoperative vascular diagnosis allowing radical tumoral resections while preventing damage to the internal carotid artery.

The variations in anatomy of the sphenoid sinus and sellar floor to perform transsphenoidal endoscopy in adult age

Transsphenoidal surgery depends on the ability to visualize and identify key anatomical landmarks during each phase of the operation. A remarkable degree of anatomical variation exists in the sphenoid sinus, sella turcica, and surrounding skull base structures. Our purpose is to review the anatomical variations in sphenoid sinus and sellar floor that are important to performing safe and effective transsphenoidal endoscopic surgery in adult patients. Detailed information regarding the anatomy is the most reliable and effective way of avoiding complications of all kinds in transsphenoidal surgery.