Transition From Microscopic to Endoscopic Transsphenoidal Surgery: Challenges, Advantages, and Early Surgical Outcomes.

Microscopic and endoscopic transsphenoidal approach (TSA) are major surgical techniques in the treatment of pituitary adenoma. Endoscopic endonasal transsphenoidal approach (EETSA) has been increasingly used for pituitary adenomas, however, its surgical outcome particularly in functioning pituitary adenoma has been debated. Here, we investigated the endocrine outcome of the patients with growth hormone (GH) and adrenocorticotropic hormone (ACTH) secreting pituitary adenoma treated by EETSA. We treated 80 patients with pituitary adenoma by EETSA since 2004, of which 12 patients were affected by functioning pituitary adenomas (9 GH, 3 ACTH, 0 PRL; 9 macro, 3 micro). Surgical outcome of those patients treated by EETSA was compared with that of the 11 functioning pituitary adenoma patients (8 GH, 3 ACTH; 8 macro, 3 micro) who underwent sublabial microscopic TSA between 1997 and 2003. Imaging remission based on postoperative MRI was achieved in 8 (73%) and hormonal remission in 5 (45%) of 11 patients treated by sublabial microscopic TSA. Imaging remission was observed in 10 (83%, p=0.640) and hormonal remission in 10 (83%, p=0.081) of 12 patients by EETSA. CSF leakage was noticed in 2 (17%) of EETSA group and in 2 (18%) of sublabial microscopic TSA group. Panhypopituitarism was observed in 1 (9%) of EETSA group and in 3 (27%) of sublabial microscopic TSA group. EETSA appears to be an effective and safe method for the treatment of functioning pituitary adenomas.

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

Pituitary adenomas are benign tumors with various biological behaviors, including hormonal secretion, cavernous sinus invasion and others. This study aimed to access the advantages and disadvantages of the endoscopic endonasal transsphenoidal (EET) approach for managing growth hormone-secreting adenomas in achieving clinical remission compared to the microscopic endonasal transsphenoidal (MET) approach. From 2017 to 2020, a series of 29 patients with growth hormone-secreting adenomas (GH) underwent the surgical treatment via MET (n = 13) and EET (n = 16) approach. Preoperatively and postoperatively endocrinological, neuro-ophthalmological and magnetic resonance imaging (MRI) examinations were performed. According to the Knosp classification for cavernous sinus, 34.4% of all adenomas were accessed as invasive. The mean follow-up was 21.6 ± 12.2 months. The endocrinological remission in the whole group was 68.9%. The microscopic group had lower levels of remission in comparison to the endoscopic group (61.53% vs. 75%). However, no significant difference was observed (р > 0.05). Postoperative diabetes insipidus and cerebrospinal fluid (CSF) leaks rates had a similar occurrence in both groups. No other significant complications were recognized. The use of endoscopic approaches provides a couple of advantages, such as wider field of view, superior illumination and better maneuverability compared to conventional microsurgery. A longer follow-up is still needed for further evaluation of our results.

Endoscopic Endonasal Transsphenoidal Removal of Recurrent and Regrowing Pituitary Adenomas: Experience on a 59-Patient Series

Is Olfactory Function Affected by Endoscopic Transsphenoidal Skull Base Surgery?

The most common surgical technique for the management of pituitary adenomas is the endoscopic endonasal transsphenoidal approach (EEA). preoperative neuroimaging along with detecting surgical landmarks of the sphenoid sinus during surgery is important for making a successful operation. This study includes 1009 patients with pituitary adenomas who underwent EEA between 2013 and 2020. We evaluated the anatomical features of the sphenoid sinus through a panel of items obtained from imaging and intra-operative findings. Our result includes 57.38% nonfunctional, 8.42% cushing, 12.39% prolactinoma, and 21.8% acromegaly patients who had undergone endoscopic endonasal transsphenoidal surgery. The mean age of the patients was 45 with a male to female ratio of 1.2:1. Sellar sphenoid type was the most common (91.8%) with only 12% symmetrical inter sphenoid septa, Internal carotid artery dehiscence was found in 1.7% of the cases. Apoplexy was present in 6.3% of patients, which was found more prevalent in nonfunctional adenomas (9.67%, Odds ratio: 4.85, 95% CI 2.24-11.79) and further investigation revealed a significant association between apoplexy and sphenoid mucosal edema and hemorrhage (Odds ratio: 43.0, 95% CI 22.50-84.26), and between apoplexy and cystic lesions (OR = 4.14, 95% CI 1.87-8.45, P-value < 0.0001). Acromegaly is associated with the increased number of lateral recces (Odds ratio: 11.41, 95% CI 7.54-17.52), septation of the sphenoid sinus (Marginal mean: 3.92, 95% CI 3.69-4.14), edematous sinonasal mucosa (Odds ratio: 6.7; 95% CI 4.46-10.08), and higher bony (OR: 4.81, 95% CI 2.60-8.97, P-value < 0.001) and cavernous (OR: 1.7, 95% CI 1.13-2.46, P-value < 0.01) invasion. The present study provides anatomical data about the sphenoid sinus and its adjacent vital structures with adenomal specific changes that are necessary to prevent complications during endoscopic advanced transsphenoidal surgery.

Objective To investigate the safety and effectiveness of endoscopic endonasal transsphenoidal surgery in old patients with non-functional pituitary adenoma. Methods From January 2009 to December 2014, the clinical data of 34 patients (≥65 years) with non-functional pituitary adenoma treated with endoscopic endonasal transsphenoidal surgery at the Department of Neurosurgery, Wuxi Second Hospital Affiliated to Nanjing Medical University were analyzed retrospectively. Twelve patients were treated unilaterally by transnasal endoscopic operation and 22 were treated bilaterally by transanal endoscopic surgery. Results The tumors of 27 patients (79.4%) were resected totally, 4 (11.8%) were resected near totally, 2 (5.9%) were resected subtotlly, and 1 (2.9%) died. The postoperative visual acuity was improved in 26 cases (92.9%, 26/28) and did not have any change in 2 cases (7.1%, 2/28). Ten patients (29.4%) had postoperative diabetes insipidus, 2 (5.9%) had cerebrospinal fluid rhinorrhea and 2 had new hypopituitarism. Thirty patients were followed up for 3 months to 5 years. Ten patients had hypopituitarism, 1 had anosmia, 1 had sinusitis, and 1 had epistaxis. Of the 6 patients with residual tumor, 2 were treated with radiation therapy after recurrence. Conclusions Although the operation risk of the elderly patients with non-functional pituitary adenoma is relatively high, using endoscopic endonasal transsphenoidal surgery is safe and feasible through the strengthening of perioperative multidisciplinary collaboration. Key words: Pituitary neoplasms; Neuroendoscopes; Transsphenoidal surgery; Aged

To analyze the clinical and imaging characteristics of patients with cystic lesions in sella region and to describe the experience of endoscopic transsphenoidal surgery. Fourty-six cases of cystic lesions in sella region confirmed by surgery and pathology between June 2003 and September 2013 were retrospectively analysed. The clinical features, imaging, surgical technique and postoperative recurrence in 46 cases were presented. All lesions were resected through transsphenoidal endoscopic endonasal approach. Followed up lasted from 6 months to 6 years. Postoperatively, headache was recovered in 26 cases and wasn't recovered in 8 cases, visual was improved in 12 cases and wasn't improved in 2 cases, hypopituitarism was relieved in 18 cases and wasn't relieved in 15 cases, polyuria was disappeared in 8 cases and wasn't disappeared in 4 cases. Seven cases recurred, including 4 cases of craniopharyngioma, 2 cases of pituitary abscess, 1 case of cystic adenoma. There were no death and serious complication. The small age of onset, visual acuity and visual field symptoms, tumor in suprasellar, third ventricle compression was easy to occur in craniopharyngioma; cystic tumor, cavernous sinus invasion, the solid part homogeneous enhancement could be seen in cystic adenoma; Rathke cyst showed simple cystic, lighter clinical symptoms and a short course. Prone to diabetes insipidus, low multiple hormone level and the lesions of annular enhancement was more common in pituitary abscess. The clinical features and imaging of cystic lesions in sella region feature overlap each other, but there are certain specificity. Transsphenoidal endoscopic endonasal approach for the surgery of cystic lesions in sella is effective and safe.

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.

To identify presurgical and surgical factors associated with the development of diabetes insipidus (DI) after pituitary adenoma (PA) resection through an endoscopic endonasal transsphenoidal approach. Data from 231 patients with functioning and non-functioning PAs who underwent an endoscopic endonasal transsphenoidal approach in the last ten years. 231 patients with 241 pituitary surgeries were included. Eighty-five percent harbored macroadenomas and 38.1% of them were invasive. After pituitary surgery, 12.5% (n = 30) developed transient DI and 5.0% (n = 12) permanent DI. The global risk of DI was higher in patients younger than 65years (OR = 2.94, p = 0.029), with total tumoral resection (OR = 2.86, p = 0.007) and with diaphragm opening during pituitary resection (OR = 3.63, p = 0.0003). Once postoperative DI developed, the risk of permanent DI increased in those patients with larger PA (OR = 1.07 for each mm of craniocaudal diameter, p = 0.020), especially in those greater than 30mm (OR = 8.33, p = 0.004). Moreover, diaphragm opening during pituitary resection (OR = 28.3, p = 0.018) predicted long-term DI independently of pituitary tumor size. The risk of permanent DI increased as PA craniocaudal diameter increased (r = 0.20, p = 0.002). In patients with PAs younger than 65years, in whom diaphragm has been opened during pituitary surgery and/or with a total tumor resection, special hydric balance monitoring should be maintained in the postoperative period due to the increased risk of developing DI. The risk of permanent DI increases as PA craniocaudal diameter increased.

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.

ObjectiveWe evaluated postoperative changes in nasal cavity volume and their effects on nasal function and symptoms after endoscopic endonasal transsphenoidal approach for antero-central skull base surgery.Study DesignRetrospective chart review at a tertiary referral center.MethodsWe studied 92 patients who underwent binostril, four-hand, endoscopic endonasal transsphenoidal approach surgery using the bilateral modified nasoseptal rescue flap technique. Pre- and postoperative paranasal computed tomography and the Mimics® program were used to assess nasal cavity volume changes at three sections. We also performed several pre- and postoperative tests, including the Connecticut Chemosensory Clinical Research Center test, Cross-Cultural Smell Identification Test, Nasal Obstruction Symptoms Evaluation, and Sino-Nasal Outcome Test-20. In addition, a visual analog scale was used to record subjective symptoms. We compared these data with the pre- and postoperative nasal cavity volumes.ResultsThree-dimensional, objective increases in nasal passage volumes were evident between the inferior and middle turbinates (p<0.001) and between the superior turbinate and choana (p = 0.006) postoperatively. However, these did not correlate with subjectively assessed symptoms (NOSE, SNOT-20 and VAS; all nasal cavity areas; p≥0.05) or olfactory dysfunction (CCCRC and CCSIT test; all nasal cavity areas; p≥0.05).ConclusionSkull base tumor surgery via an endoscopic endonasal transsphenoidal approach altered the patients’ nasal anatomy, but the changes in nasal cavity volumes did not affect nasal function or symptoms. These results will help surgeons to appropriately expose the surgical field during an endoscopic endonasal transsphenoidal approach.

Thanks to the rapid development and progress of endoscopic technology, the endoscopic endonasal transsphenoidal approach has become one of the best surgical methods for resection of sellar and suprasellar tumors. The craniopharyngioma is usually located in the sellar region or suprasellar region, which is suitable for resection through the endoscopic endonasal transsphenoidal approach. The present report describes 21 cases of craniopharyngioma treated by endoscopic endonasal transsphenoidal approach in the Department of Neurosurgery at the Chongqing General Hospital from February 2014 to September 2019. The characteristics of patients and tumors, including clinical symptoms, preoperative magnetic resonance imaging, intraoperative conditions, as well as postoperative and follow-up outcomes were evaluated. The main clinical symptoms were headache in 15 cases, visual deficiency in 13 cases and growth retardation in two cases. All 21 patients with craniopharyngioma underwent endoscopic endonasal transsphenoidal surgery. Of these, 20 patients achieved gross total resection and one case achieved subtotal resection. After surgery, headache symptoms improved in 11 patients without deterioration and the vision of 11 patients improved without deterioration. The primary postoperative complications were pituitary deficiency in eight cases and permanent diabetes insipidus in five cases. The patients were followed up from one to 52 months post-operation. There was no recurrence in all patients during the follow-up period. The endoscopic endonasal transsphenoidal approach is a safe and effective resection for craniopharyngioma. Moreover, the endoscopic endonasal trans-sphenoidal approach is one of the preferred surgical methods for treatment of sellar or suprasellar tumor.

ObjectivesTo study the effect of endoscopic endonasal transsphenoidal surgery on voice quality in patients with pituitary lesions.MethodsAn observational study comparing voice quality before and after surgery was conducted between September 2015 and September 2017 at Srinagarind Hospital, Khon Kaen University, Thailand. Pituitary tumor patients who underwent endoscopic endonasal transsphenoidal surgery were recruited. The nasal corridors were created with a type I (preserving both middle turbinates with a rescue flap) or type II (cutting one middle turbinate with a raised nasoseptal flap) for the binostril with four‐hand technique. All patients were evaluated for nasal resonance, acoustic parameters, acoustic perception, and self‐assessment of their satisfaction with postoperative voice changes with a visual analog scale (VAS). The patients were evaluated 1 day before surgery and at 1 and 3 months after surgery.ResultsForty‐four patients, including 19 males and 25 females with a mean age of 50.0 ± 15.6 years, were enrolled. Mean scores for nasal resonance and all acoustic parameters were not significantly changed after surgery for either nasal corridor type (p > .05). Regarding acoustic perception, word and sentence and GIRBAS scores showed no significant difference before and after surgery (p > .09) in either type of nasal corridor. There was no incidence of hypernasality voice after surgery. Patients' self‐satisfaction ratings (i.e., VAS) with voice quality were high and showed no significant change 1 and 3 months postsurgery (p > .05).ConclusionsThese endoscopic endonasal transsphenoidal approaches are minimally invasive skull base surgery techniques that have minimal effects on postsurgery voice quality.Trial RegistrationThis trial was registered at ClinicalTrial.gov (NCT02828514).Level of Evidence4.

Objective To present our experience with the surgical management of giant pituitary adenomas through endoscopic endonasal transsphenoidal approach. Methods A retrospective data analysis of all patients who underwent endoscopic endonasal transsphenoidal surgery in Nanfang Hospital between January 2007 and June 2013 was performed. Patients who presented with pituitary adenomas larger than 4 cm were included in the study. Analysis of factors related to the choice of the operative approach, extent of resection, follow-up outcome, and complications were evaluated. Results Sixty-nine patients (18%) with giant adenomas matched our inclusion criteria. This included 51 (74%) patients with nonfunctional tumors, 11 (16%) prolactinomas, and 7 (10%) growth hormone-secreting adenomas. Gross total removal of the tumor was achieved in 26 cases (38%), subtotal removal in 23 (33%), and 20 (29%) had partial resection. Postoperative diabetes insipidus occurred in 9 cases (13%), new anterior pituitary insufficiency in 10 (15%), CSF leaks in 2 (3%), and meningitis in 2(3%). There was no dead case. The patients with Knosp score 3-4 adenomas had a higher total resection rate than those with Knosp score 0-2 (P< 0.001). Preoperative headache, visual dysfunction, oculomotor disorders and hypopituitarism were recovered in 20(83%), 59(86%), 9(60%), and 12(36%) cases, respectively. Nine patients with nonfunctional tumors underwent a second transsphenoidal surgery, 10 underwent radiotherapy, and 14 had a follow-up care. Drug therapy was performed in 11 patients with functional tumors, and radiotherapy in 3. Conclusions Endoscopic endonasal surgery might provide safe and effective treatment for patients with giant adenomas. The selection of surgical approach should be established according to the tumor extension and personal experience. In cases in which total resection might be associated with high risk, we advocated the use of partial resection followed by adjuvant drug therapy or radiotherapy. In cases of progressive enlargement of residual lesions, a second endoscopic procedure or radiotherapy might be considered. Key words: Endoscopy; Giant pituitary adenomas; Transsphenoidal surgery