Endoscopic Transsphenoidal Surgery in Growth-Hormone Pituitary Adenomas (GH PitNETs): Current Indications, Limitations, and the Importance of a Multidisciplinary Approach.

Comparative effectiveness of endoscopic versus microscopic transsphenoidal surgery for patients with growth hormone secreting pituitary adenoma: An emulated trial

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.

Endoscopic Versus Microscopic Transsphenoidal Surgery in the Treatment of Pituitary Adenoma: A Systematic Review and Meta-Analysis.

Objective To explore the effect of neuronavigation-assisted endoscopic transsphenoidal surgery for invasive pituitary adenomas. Methods A retrospective analysis was conducted on 40 patients with invasive pituitary adenomas admitted to Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University from January 2010 to March 2018. Among those patients, 20 were treated with neuronavigation-assisted endoscopic transnasal sphenoidal surgery (endoscopic group) and the other 20 were treated with traditional transnasal microsurgery (control group). The complete tumor resection rate, postoperative complication rate and tumor recurrence rate were compared between the 2 groups. Results There were no significant differences in gender, age, clinical manifestations, endocrine examination results, Knosp classification of pituitary adenomas or maximum diameter of tumors between the 2 groups (all P>0.05). The total resection rate of endoscopic group was higher than that in the control group[65.0% (13/20) vs. 20.0% (4/20), P 0.05). Conclusion Neuronavigation-assisted endoscopic transnasal sphenoidal surgery for invasive pituitary adenomas is associated with higher total resection rate and lower recurrence rate compared with traditional transnasal sphenoidal microsurgery. Key words: Pituitary neoplasms; Neoplasm invasiveness; Neuronavigation; Natural orifice endoscopic surgery; Treatment outcome

Objective: To compare clinical outcomes of large pituitary adenomas (≥3 cm in maximum diameter), operated on by Endoscopic Transsphenoidal Surgery (ETS), versus Microscopic Transsphenoidal Surgery (MTS).Methods: Medical records and MRI Scans of patients with a diagnosis of pituitary adenoma for whom transphenoidal surgery was done were reviewed. Complete pre and post-operative data were available for 121 patients. Thirty five patients had large pituitary adenoma and were enrolled in this study. ETS was done in 16 patients, and 19 underwent MTS. All patients were followed for at least six months. Clinical and imaging characteristics were reported in details. Post-operative clinical outcomes were defined as clinical outcomes persisted 6 months after surgery.Results: The average tumor size was 36.3 ± 4.4 mm in ETS group, and 34.0 ± 4.6 mm in MTS group, (p = .46). Six months after surgery, tumor size was 4.6 ± 6.6 mm in ETS and 17.7 ± 12.2 mm in MTS group, (p = .002). Gross total resection (GTR) was observed in the 81.2% of the patient in the ETS group. In the MTS group, GTR was observed in 15.8%.Post-operative clinical outcomes including new onset hypopituitarism, visual impairment, and permanent diabetes insipidus (DI) were comparable between the two groups.Conclusion: ETS is superior to MTS in treatment of large pituitary adenomas with comparable post-operative complications.

Background:The comparative efficacy of endoscopic versus microscopic transsphenoidal surgery for patients with pituitary adenoma (PA) remains controversial. Previous retrospective studies have often been limited by inconsistencies in baseline characteristics of patients, which may affect the validity of the comparisons. This study aimed to evaluate the trend in the proportion of transsphenoidal endoscopic and microscopic surgeries in China and compare outcomes in comparable patients.Materials and methods:The National Brain Tumor Registry of China (NBTRC) database was queried to extract PA patients (2011–2021) for trend analysis. Stratified sampling was performed, and a 1:1 propensity score matching (PSM) was used to balance the patients’ baseline characteristics. Postoperative outcomes, complications, and prognosis were compared.Results:Among the nationwide 17 012 PA patients, there was a gradual increase in the proportion of endoscopic surgeries (annual percent change, 11.89%). Among the 1863 stratified patients, those who underwent endoscopic surgery had a higher preoperative recurrence rate and higher Knosp and Hardy grades (P < 0.05). Endoscopic surgery showed a similar gross total resection (GTR) rate to microscopy (55.6% vs. 54.9%, P = 0.886) in the real-world cohort and a higher GTR rate (59.5% vs. 54.3%, P = 0.037) in the PSM cohort. After PSM, there was no significant difference in cerebrospinal fluid leak and secondary surgery (P > 0.05); endoscopic surgery showed more bleeding, longer surgical time, shorter hospital stay, and higher costs (all P < 0.001) compared to microscopic surgery. The risk of postoperative progression was similar between endoscopic and microscopic surgeries for comparable PA patients (P = 0.45).Conclusion:Endoscopic transsphenoidal surgery is increasingly adopted in China, demonstrating a higher GTR rate than microscopic transsphenoidal surgery in PA patients with similar characteristics, without increasing severe complication rates. The risk of postoperative progression was similar between the two techniques.

Objective To analyze the outcomes of neuro endoscopic and microscopic pituitary adenoma surgery. Methods A total of 862 cases were enrolled in between October 2010 and October 2011, including 226 cases in endoscopic group and 636 in microscopic group. The extent of tumor resection, visual improvement, operation time and hospitalization days were compared between two groups. Results There was no statistical difference in the extent of tumor resection in microadenomas and giant pituitary adenomas between two groups. While endoscopic surgery resulted in superior resection in macroadenomas. Analyzed by Knosp grading, according to the removal rates, there was no significant difference showed at Knosp level 0-2 and level 4, while endoscopic surgery resulted in superior resection at level 3(P<0.05). The visual acuity and visual field were better in the endoscopic group. The operation time and length of stay in hospitals were both shorter in the endoscopic group than those in the microscopic group. Conclusions Endoscopic transsphenoidal resection of pituitary tumors was safe, with shorter operation time and length of stay. Endoscopic and microscopic transsphenoidal operations had their own advantages, and the advantage of endoscopic transsphenoidal surgery lied in the treatment of invasive adenoma of Knosp 3 grade. Key words: Neuroendoscopes; Microsurgery; Pituitary neoplasms; Prospective studies; Transnasal transsphenoidal approach

IntroductionThe present study analysed the (i) remission and preservation of hormones, (ii) endocrinological and anatomical complications and (iii) visual improvement after endoscopic transsphenoidal surgery (ETS).MethodsThe retrospective observational study of all consecutive cases of pituitary adenoma treated with ETS in Hospital Kuala Lumpur (HKL) between 2006 and 2015. Age, sex, pre- and post-operative hormone level, tumour size, and complications were noted.ResultsA total of 67 patients were diagnosed with non-functioning pituitary adenoma throughout this period. Of these, 11 patients had both visual and hormonal improvement post-operation. Of the 27 patients with tumour invaded into the cavernous sinus, 13 showed an improved vision. In the adenoma patients who had impaired hormonal function before the surgery, the hormone level normalised post-surgery in 42 patients. Moreover, 39 patients were diagnosed with functioning pituitary adenoma. Ten patients recovered from acromegaly and four patients recovered from Cushing disease within seven days post-operative. Also, five patients with functioning adenoma suffered complications.ConclusionOutcome for the preservation and hormone recovery in non-functioning pituitary adenoma group was satisfactory, with only one patient’s hormonal level worsening. No visual deterioration and mortality were detected throughout this study. A dedicated team specialised in endoscopic transsphenoidal pituitary surgery further improved the outcome of this surgical method.

Objective To investigate the efficacy of transsphenoidal endoscopic surgery for acromegaly. Methods The clinical data of 210 consecutive patients with acromegaly operated with transsphenoidal endoscopic surgery from January 2007 to January 2014 were analyzed retrospectively. The patients with preoperative higher surgical risk used long-acting somatostatin analogue octreotide. Surgery was conducted in combination with intraoperative high field magnetic vesonance imaging and neuronavigation, postoperative head MRI and endocrine were followed up, including biochemical indicators, such as growth hormone and insulin-like growth factor-1. The patients with residual tumor and without remission of endocrine chose octreotide or radiosurgery according to the specific situation. Results There were 129 males and 81 females, their age ranged from 21 to 67 years old (mean 40.7 years). Preoperative MRI revealed that the maximum diameter of the tumors in 183 patients (87.1%) was >1 cm. Three patients were treated with octreotid before procedure. The tumors of 171 patients (81.4%) were resected completely, 22 (10.5%) were resected subtotally, and 17 (8.1%) were resected partially. There were no procedure-related deaths in this group. Postoperative achieved endocrine remission in 148 cases (70.5%). The average growth hormone level before procedure was decreased from 27 ng/mL (range 4 to 150 ng/mL) to 5 ng/mL (range 0 to 32 ng/mL) after procedure. A total of 184 patients were follow-up for 3 to 84 months (mean 27.5 months). During the follow-up period, the subjective symptoms of 161 patients (87.5%) were improved and returned to the daily work and study. In patients who had residual tumors and did not achieve endocrine remission after procedure, 34 were treated with octreotide after procedure and 29 accepted radiosurgery. Conclusion Transsphenoidal endoscopic surgery is the preferred treatment option for acromegaly. Patients should regularly examine the head MRI and endocrine after procedure. The treatments of octreotide and radiosurgery may control the residual tumors and improve endocrine. Key words: Pituitary neoplasms; Acromegaly; Endoscopic; Neurosurgical procedures

Objective: To explore the techniques and methods of endoscopic transnasal transsphenoid surgery for pituitary adenoma.Method: We treated 678 cases with pituitary adenoma by endoscopic transsphenoidal surgery between May 2000 and May 2006. All cases were operated through a transnasal transsphenoid approach between the nasal septum and middle nasal concha, first to enlarged sphenoid ostium and opened sellar floor with a high-speed drill and then removed the tumor step by step. Sixty-two percent of cases (420 cases) got 6–24 months of follow-up.Results: Among the 678 pituitary adenomas, tumor removal was total in 543 (80.1%), subtotal in 118 (17.4%) and partial in 17 (2.5%). Ninety-eight percent (643 of 655 cases) obtained an improvement in clinical symptoms at some extent after the operation. Post-operative complication (including subarachnoid hemorrhage, nasal cavity bleed, nostril infection, nasal wing deformation and cerebrospinal fluid nasal leakage) occurred in 21 patients (3%). Among the 420 follow-up patients, tumor in four cases recurred 2 years after the first operation.Conclusion: Endoscopic transsphenoidal surgery of pituitary adenomas is a valuable microinvasive neurosurgery technique of minimal invasiveness, being effective and safe, yet requiring simple manipulation. With technological and scientific advancements, endoscopic transsphenoidal surgery will improve and develop step by step.

Stent-Assisted Coil Embolization for a Ruptured Posterior Communicating Artery Pseudoaneurysm After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma

Background: Advances in the era of modern micro-neurosurgery enabled a reduction of surgical invasiveness and brain retraction which has been defined as minimally invasive or keyhole surgery. Sinonasal endoscopy has brought radical changes in the concepts of pathophysiology and treatment of sinonasal aliments as well as surgical techniques. Aim of the Study: To compare between the use of endoscopic and microscopic trans-sphenoidal approach in resection of growth hormone-secreting pituitary adenomas with Suprasellar Extension. Patients and Methods: This is a prospective study. It had been conducted upon 20 patients having growth hormone secreting pituitary adenoma admitted to Neurosurgery department in Alzar University hospitals and Nasr City Insurance hospital from 2015 to 2018, divided into 2 groups; group A (10 cases) underwent endoscopic endonasal trans-sphenoidal pituitary adenoma resection, while group B (10 cases) operated upon using the standard microscopic trans-sphenoidal pituitary adenoma resection. The inclusion criteria were included: All patients with growth hormone secreting pituitary adenomas showing manifestations of acromegaly, mass effect or hormonal disturbance. Results: This study showed that improvement in outcome was higher in endoscopic group opposed to microscopic group (100% vs. 71% improved headache, 80% vs. 60% visual improvement, 75% vs. 20% fundus improvement and 60% vs. 30% field improvement). Conclusion: We concluded that fully endoscopic procedure result in improved rates of complete tumor removal and a reduced incidence of complications, when compared to the microscopic approach.

Endoscopic endonasal transsphenoidal approach (Endonasal approach) is commonly used to treat pituitary adenomas. The extent of dissection possibly changes the anatomy and the physiology of the nasal cavities and could give rise to post-operative morbidity and the quality of life (QoL). The purpose of this study was to investigate sinonasal morbidity and general QoL in patients who underwent surgery for treatment of pituitary adenoma, comparing Endonasal and endoscopic trans-septal transsphenoidal approach (Trans-septal approach). A prospective observational study, recruiting 40 patients undergoing surgery for pituitary adenoma, 20 via Endonasal approach and 20 via Trans-septal approach at our institution. Surveys with Sinonasal Outcome Test-22 (SNOT-22), Chronic Sinusitis Survey (CSS), and Short Form Health Survey 36 version 2 (SF-36v2) were obtained to collect QoL data pre- and postoperatively. All the 40 patients completed the questionnaires. At 6months postoperatively, the SNOT-22 and CSS score shows significant improvements both in Endonasal approach (p = 0.01) and in Trans-septal approach (p = 0.02). No significant difference in sinonasal morbidity is observed between the two groups for SNOT-22 (p = 0.13) and CSS scores, except for sinus headache (p = 0.49), with a better score in Endonasal approach. The mean SF-36v2 scores remain the same in pre- and post-operative periods, but an improvement in time is seen in general health (p = 0.027), and general health compared to one year ago (p < 0.001). Endoscopic transsphenoidal surgery has negligible morbidity and does not negatively affect the nasal function in the long term. Endonasal approach and Trans-septal approach are comparable in terms of morbidity outcomes and general QoL, leaving the choice of the approach to the surgeon preference.

Introduction: Pituitary adenoma resection via the transsphenoidal approach (TSS)is a safe and common neurosurgical procedure that can be done both through microscopic and endoscopic methods. Objectives: The main objective of the study is to find the frequency of CSF rhinorrhoea in patients undergoing endoscopic transsphenoidal surgery (ETSS) for pituitary macroadenoma. Material and methods: The study data was collected from 1st Oct to 1st Nov 2022, in the departments of Neurosurgery of Hayatabad Medical complex, Khyber Teaching Hospital, Lady Reading Hospital, Peshawar. The data was collected through non-probability consecutive sampling technique. There were 315 patients which were included in the study. The surgical procedure is done under general anesthesia. All patient data was collected and a standardized form was filled by the attending surgeon caring for the patient. Importantly, the primary end points to be recorded were: (1) techniques of intraoperative cranium base reconstruction used, and (2) postoperative CSF rhinorrhoea biochemically confirmed and/or requiring intervention (CSF diversion and/or operative restoration). Results: Of the 315 consecutive patients diagnosed with pituitary adenomas, a total of 250 patients met the inclusion criteria and were included. The pathology included 187 (74.8%) non-functioning adenomas, 40 (16.0%) GH-secreting pituitary adenomas, 3 (1.2%) PRL-secreting pituitary adenomas, and 20 (8.0%) ACTH-secreting pituitary adenomas. There were 30 (12.0%) cases of microadenomas, 205 (82.0%) cases of macroadenomas, and 15 (6.0%) cases of giant adenomas. Intraoperative CSF leakages were determined throughout surgical procedure in eighty patients (32.0%). Postoperative CSF leaks occurred in 9 patients (3.6%), including seven patients with intraoperative CSF leaks. Practical implication: Practical implications of this study is: (1) easily find the CSF leakage (2) frequency of CSF rhinorrhoea in patients undergoing endoscopic transsphenoidal surgery Conclusion: It is concluded that macroadenoma ETSS surgery should be strictly monitored for post-operative CSF leakage and lumber drain is an effective prophylactic strategy. Keywords: Postoperative CSF Leakage, Pituitary Adenomas, ETSS, Surgery, Lumber

Until today, it is unclear if endoscopic or microscopic transsphenoidal surgery is the most adequate treatment technique for pituitary adenoma, while microscopic transsphenoidal surgery is termed as a fully-established mechanism that has reasonable performances and is well recognized for addressing adenomas of the pituitary gland. The present research work aims at assessing the short-term results of these surgical methodologies in those patients, who have pituitary adenoma. The authors comprehensively searched PubMed, together with EMBASE, and Cochrane Library databases for the purpose of identifying associated investigations. The strength of the relationship was figured out through the calculation of the risk ratio (RR) with corresponding 95% credible interval (95% CI) were put to use for the evaluation of the association. An aggregate of 17 retrospective studies that involved 1177 participants were included in the present research work. Our results shed light on the fact that endoscopic transsphenoidal surgery was linked to the lower occurrence of diabetes insipidus (RR = 1.42, 95%CI = 1.03-1.98, P = 0.03), fewer septal perforation (RR = 3.16, 95%CI = 1.27-7.85, P = 0.01), and fewer postoperative complications (RR = 1.29, 95% CI = 1.08-1.56, P = 0.006). Moreover, further analyzing indicated no substantial differences existing between the 2 surgical methods in gross tumor removal, meningitis, epistaxis, and cerebrospinal fluid leak. Endoscopic transsphenoidal surgery reduces diabetes insipidus, septal perforation, and postoperative complications in treating those patients, who have pituitary adenoma. Endoscopic transsphenoidal surgery is worth suggesting as a productive as well as secure process for the treatment of pituitary adenoma.