Endoscopic Endonasal Transsphenoidal Approach Research Articles

Surgical outcome of endoscopic endonasal surgery for non-functional pituitary adenoma by a team of neurosurgeons and otolaryngologists

This study aimed to assess the efficacy of endoscopic endonasal surgery, conducted by a team of neurosurgeons and otolaryngologists. We studied 40 patients who were undergoing surgery for primary non-functional pituitary adenomas with Knosp grades 1 to 3, at Keio University Hospital between 2005 and 2012. We compared the endoscopic endonasal transsphenoidal approach (team-eTSS; T-eTSS), with a microscopic transsphenoidal approach (mTSS). Analyses were conducted for differences between the two groups in tumor resection rates, operating durations, and complications from the non-functional pituitary adenomas. We also compared the heminostril and binostril approaches for T-eTSS. Tumor resection rates were higher when the surgeries were conducted by T-eTSS than mTSS. In particular, when the maximum tumor diameter was more than 25 mm, resection rates were significantly higher for T-eTSS than for mTSS. There were no unexpected complications in either group. There was no significant difference in resection rates between the heminostril and binostril approaches when T-eTSS was performed. T-eTSS is an efficacious surgical option for non-functional pituitary adenomas, particularly when the adenoma is of large size. Benefits of the heminostril approach are evident.

Endoscopic endonasal transsphenoidal approach for resection of a coexistent pituitary macroadenoma and a tuberculum sellae meningioma

The coexistence of a pituitary macroadenoma and a tuberculum sellae meningioma is very rare. This article demonstrates the surgical technique of the simultaneous resection of a pituitary macroadenoma and a tuberculum sellae meningioma using an endoscopic, endonasal, biportal, transsphenoidal approach. A 36-year-old woman presented with frontal headache and extended visual field loss of the right eye. She underwent cranial magnetic resonance imaging (MRI) revealing a 2 × 2 × 2.5 mm contrast-enhancing intrasellar and suprasellar lesion with compression of the optic chiasma. The coexistence of a pituitary macroadenoma and meningioma was suggested. A biportal endoscopic endonasal transsphenoidal approach was performed to remove both lesions. The histological results confirmed the coexistence of the pituitary macroadenoma and meningioma, World Health Organization (WHO) grade I. The endoscopic, endonasal, transsphenoidal approach is a safe and reliable minimal invasive surgical alternative for resection of the intra-, supra- and parasellar lesions, avoiding additional craniotomy.

Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading cavernous sinus

Objective To investigate the effects of endoscopic endonasal transphenoidal approach in the treatment of pituitary adenomas invading the cavernous sinus (CS).Methods A retrospective analysis was performed in 135 pituitary adenomas extending to CS treated via endoscopic endonasal transphenoidal approach between April 2008 and April 2013.The most common adenoma type was non-functioning pituitary adenomas (NFPAs) (86 cases,63.7％),followed by PRL-secreting adenomas (28 cases,20.7％),growth hormone (GH)-secreting adenomas (18 cases,13.3％),ACTH-secreting adenomas (2 cases,1.5％),and TSH-secreting adenomas(1 cases,0.7％).The average diameter of the tumors was (30.0 ± 1.1)mm(10-69 mm).The shapes of the tumors were as the following:round (97 cases,72.6％),dumb bell (8 cases,5.9％),and multi-lobe (30 cases,21.5％).The patients were divided into two groups according to the Knosp classification:third grade (57 cases,42.2％) and fourth grade (78 cases,57.8％).Results Gross total resection was achieved in 40 patients (29.6％),subtotal (＞90％) in 45 (33.3％),partial (＞70％) in 42 (31.1％),and decompression (＜70％) in 8 (5.9％).There were 4 patients (3.0％) accompanied with postoperative cerebraospinal fluid leak,2 with visual decrease,and 5 with transient diabetes insipidus.One paient died due to postoperative intracranial hematoma.In 18 patients with GH-secreting adenomas,4 achieved endocrinological remission after surgery,and 9 significant GH decrease.In 28 patients with PRL-secreting adenomas,6 had a normal serum PRL level within one week postoperatively,and 21 remarkable PRL decrease.Conclusions The endoscopic endonasal transphenoidal approach was a safe and effective option for the resection of pituitary adenomas invading the CS. Key words: Pitutiary adenomas; Invasive; Caverous sinus ; Neuroendoscope ; Endonasal transsphenoidal approach

Endoscopic transsphenoidal surgery of Rathke’s cleft cyst

Rathke’s cleft cysts (RCC) are benign lesions that originate from remnants of Rathke’s pouch. They can compress adjacent structures causing visual loss and endocrine dysfunction. The endoscopic endonasal transsphenoidal approach (EETA) has gained popularity in the surgical management of pituitary and parasellar tumors. However, postoperative cyst recurrence and endocrine dysfunction are still major concerns. A retrospective chart review was performed on 11 patients who underwent a purely EETA. Subtotal resection of the cyst wall with drainage of the intracystic contents followed by obliteration of the cyst with a fat graft was performed in all patients. Two patients underwent repeated surgeries for symptomatic cyst recurrence. One patient ultimately underwent extracapsular removal of the entire cyst wall because of multiple recurrences after simple drainage. There were no incidences of new permanent hypopituitarism, visual deficits, or postoperative cerebrospinal fluid leaks. All patients reported an improvement of initial preoperative symptoms. A non-aggressive strategy of partial cyst wall removal and simple drainage of cyst contents via EETA is a viable approach for surgical treatment of RCC with a low rate of postoperative endocrine and visual complications. A more aggressive strategy of extracapsular removal of the cyst wall may be indicated in patients with repeated recurrence.

Endoscopic endonasal surgery for pituitary tumors. Results in a series of 121 patients operated at the same center and by the same neurosurgeon

Abstract Introduction Pituitary adenomas account for approximately 15% of intracranial benign tumors. The neurosurgical results achieved since the endoscopic endonasal transsphenoidal (EET) approach was introduced in our center in 2005 are reported here. Patients and methods A retrospective analysis of 121 patients with sellar lesions (58% females, age 55.7 ± 16 years, range 18–82) who underwent EET surgery from February 2005 to January 2012 and were followed up for a mean time of 4.58 years (range 1.08–8.58). Results Six Rathke cleft cysts (3 intra-suprasellar, 1 intrasellar, 2 suprasellar); 114 pituitary adenomas (16 microadenomas, 98 macroadenomas), and 1 case of normal MRI were included. Baseline findings included hormonal changes in 59 patients (48.7%) and visual field changes in 38 patients (31%); in 7 patients (5.8%), clinical presentation was pituitary apoplexy. Complete resection was achieved in 77 patients (63.6%), subtotal resection in 29 (23.9%), and partial resection in 15 (12.3%). In patients with Grade 3 and 4 cavernous sinus invasion, resection was subtotal in 30% (12/39) and complete in 46% (18/39). Hormonal remission was achieved in 16 patients with Cushing disease (84%), 18 patients with prolactinoma (78.2%), and 18 patients with acromegaly (85.7%). There were 12 cases (9%) of cerebrospinal fluid leak, 4 cases of diabetes insipidus, and 3 cases with transient SIADH/hyponatremia. Seven patients developed panhypopituitarism. Postoperative mortality rate was 2.4%. One hundred and three patients (85.3%) were discharged from the hospital less than 48 h after surgery. Conclusion Our results are similar to those reported by renowned pituitary units. Results achieved using an endoscopic approach in pituitary neurosurgery are better than those of microneurosurgery for cavernous sinus invasion.

Endoscopic Endonasal Transphenoidal Approach for Pituitary Adenomas: Outcomes of Our Center

Objectives: Report the results of a consecutive series of patients who underwent an endoscopic endonasal transphenoidal approach (EETA) for resection of a pituitary adenoma. Methods: A retrospective review of patients who underwent EETA at our center between 2010 and 2013, in a collaboration between head and neck surgeons and neurosurgeons, and a description of the technique used. Results: Nineteen patients underwent an EETA for removal of a pituitary adenoma. Decreased visual acuity or a visual field defect was the presenting complaint in 63.2% patients and headache in 26.3%. Nonfunctioning adenoma was the most frequent (52.6%). Sixteen (84.2%) patients had a macroadenoma (>1 cm) and 3 (15.8%) had a microadenoma (<1 cm). The overall postoperative cerebrospinal fluid leak rate was 5.3%. Other perioperative complications were epistaxis (5.3%), postsurgical hematoma (5.3%) with urgent evacuation, and meningitis (5.3%). The rate of gross total ressection was 70% in patients with nonfunctioning adenomas. The remission rate of secretory adenomas was 75%. Of the patients presenting with visual symptoms, 91.7% improved or normalized. Conclusions: EETA is an excellent alternative to other classic approaches for pituitary adenoma, providing similar results with less morbidity. It allows a better panoramic visualization of sellar and parasellar spaces and a better preservation of the normal anatomy and physiology of nasal cavity. This minimally invasive approach is now the standard of care in transasal pituitary surgery. Our outcomes, including remission and complication rates, are comparable with those reported in previous series of endoscopic and microscopic approaches.

Extended endoscopic endonasal approach for recurrent or residual adult craniopharyngiomas.

The aim of this study was to evaluate the effectiveness of the extended endoscopic endonasal transsphenoidal approach (TSA) for recurrent or residual craniopharyngiomas, focusing on the extent of tumor resection and complications resulting from surgery at a single institution. Twelve adult patients (six men and six women) underwent extended endoscopic endonasal TSA for a recurrent or residual craniopharyngioma after a previous surgical intervention at a single institution by a single surgeon. The mean number of surgeries patients had undergone before TSA was 1.3 (range, 1-3). The mean period between patients' most recent surgery and extended TSA was 55.9 months (range, 1-184). The mean preoperative (that is, pre-extended TSA) tumor volume was 2.87 cm³. The mean follow-up period was 15.8 months (range, 4-32). We reviewed clinical and radiological features in each case, focusing on the degree of tumor resection as well as endocrinological and ophthalmological outcomes. Gross total resection was achieved in ten patients (83.3 %), and the mean resection rate was 87 % in the other two cases. There were no significant differences between pre- and postoperative endocrine function, except in one patient who suffered postoperative panhypopituitarism resulting in pituitary stalk resection, which was necessary because of obvious tumor involvement. Three patients suffered transient diabetic insipidus (DI). With respect to ophthalmological outcomes, three patients showed improvement, two others showed decline, and the remainder showed no significant changes. The extended endoscopic endonasal transsphenoidal approach is an effective and safe surgical approach for treating recurrent or residual craniopharyngioma.

Risk Factors Predicting Nasoseptal Flap Failure in Endoscopic Endonasal Transsphenoidal Approach

Objective: Reconstruction of the skull base using pedicled nasoseptal flap (NSF) seems to be advantageous after endoscopic endonasal transsphenoidal approach (EETSA). There were few reports to evaluate the cause of flap failure in EETSA using NSF. The aim of this study was to evaluate the perioperative risk factors for NSF failure. Methods: The study population comprised of patients who underwent EETSA with NSF elevation between February 2009 and November 2013. We retrospectively reviewed patients' medical records including operative findings. Results: A total of 374 patients (183 men, 191 women) underwent the EETSA and 310 patients underwent the EETSA with NSF elevation including modified nasoseptal rescue flap. The mean patient age was 48.0 years. The total cases of NSF failure were five (overall rate: 1.61%, 5/310; flap elevation: 0.35%, 1/282; flap reconstruction: 14.2%, 4/28). Two patients had diabetes mellitus. One patient had cardiovascular problems. Five patients had old age (mean 70 years, >60). Four patients had postoperative nasal infection. One patient had a radiation therapy. Conclusion: NSF is usually safe and effective technique for skull base reconstruction. However, the condition of diabetes mellitus, cardiovascular problems, an old age, postoperative nasal infection, and radiation therapy must require more attention to improve patient management and NSF survival.

Cirugía endoscópica endonasal en tumores de hipófisis. Resultados en una serie de 121 casos operados en un mismo centro y por un mismo neurocirujano

IntroductionPituitary adenomas account for approximately 15% of intracranial benign tumors. The neurosurgical results achieved since the endoscopic endonasal transsphenoidal (EET) approach was introduced in our center in 2005 are reported here. Patients and methodsA retrospective analysis of 121 patients with sellar lesions (58% females, age 55.7±16 years, range 18-82) who underwent EET surgery from February 2005 to January 2012 and were followed up for a mean time of 4.58 years (range 1.08-8.58). ResultsSix Rathke cleft cysts (3 intra-suprasellar, 1 intrasellar, 2 suprasellar); 114 pituitary adenomas (16 microadenomas, 98 macroadenomas), and 1 case of normal MRI were included. Baseline findings included hormonal changes in 59 patients (48,7%) and visual field changes in 38 patients (31%); in 7 patients (5.8%), clinical presentation was pituitary apoplexy. Complete resection was achieved in 77 patients (63.6%), subtotal resection in 29 (23.9%), and partial resection in 15 (12.3%). In patients with Grade 3 and 4 cavernous sinus invasion, resection was subtotal in 30% (12/39) and complete in 46% (18/39). Hormonal remission was achieved in 16 patients with Cushing disease (84%), 18 patients with prolactinoma (78.2%), and 18 patients with acromegaly (85,7%). There were 12 cases (9%) of cerebrospinal fluid leak, 4 cases of diabetes insipidus, and 3 cases with transient SIADH/hyponatremia. Seven patients developed panhypopituitarism. Postoperative mortality rate was 2.4%. One hundred and three patients (85.3%) were discharged from the hospital less than 48hours after surgery. ConclusionOur results are similar to those reported by renowned pituitary units. Results achieved using an endoscopic approach in pituitary neurosurgery are better than those of microneurosurgery for cavernous sinus invasion.

Olfactory changes after endoscopic endonasal transsphenoidal approach for skull base tumors

The increased number of endoscopic endonasal transsphenoidal approaches (EETSA) has been associated with sinonasal complications such as olfactory dysfunction. Current studies have compared preoperative and postoperative olfactory function according to surgical type and age. Retrospective review of medical records at a tertiary referral center. Patients were divided into two groups according to surgical type and into four groups according to age. The two surgical groups were defined based on the bilateral nasoseptal flap technique (group A: right conventional nasoseptal flap and left modified nasoseptal rescure flap; group B: bilateral modified nasoseptal rescue flap). The four age groups were ≤ 30, 31-45, 46-60, and ≥ 61 years. Patients underwent preoperative olfactory function evaluation using a visual analogue scale (VAS), the Connecticut Chemosensory Clinical Research Center Test (CCCRC), and the Cross-Cultural Smell Identification Test (CCSIT). Repeat testing was performed 6-months postoperatively. A total of 226 patients who underwent binostril four-hand EETSA were included in this study. In both groups A and B, the olfactory function was significantly decreased according to CCCRC and CCSIT scores (P < 0.05). The VAS scores were significantly decreased in both groups (P < 0.05). The symptom scores and olfactory test results were significantly changed in >30-year-old patients who had undergone EETSA. EETSA might contribute to olfactory dysfunction independent of surgery type. In addition, age may affect the restoration of olfaction after EETSA. Patients who plan to undergo EETSA must be informed that their olfaction may be impaired. 4.

Treatment of pituitary adenomas invading cavernous sinus with neuroendoscopy assisted by multiple techniques

To study the effectiveness of treating giant pituitary adenomas invading cavernous sinus with neuroendoscopy assisted by multiple techniques. A total of 72 patients who underwent neuroendoscopic surgery and 55 patients who underwent microscopic surgery for giant pituitary adenomas were enrolled in this retrospective analysis. Both groups received expanded endoscopic endonasal transsphenoidal approach, intraoperative application of navigation, and Doppler.The clinical data of two groups were compared. The two groups were significantly different in total tumor removal rate, operation time, postoperative nasal patency, and postoperative recurrence rate (P=0.004, P=0.0003, P=0.000, and P=0.002, respectively), whereas the cerebrospinal fluid leakage, postoperative diabetes insipidus, and cranial nerve injury were not significantly different (P > 0.05). Expanded neuroendoscopic endonasal transsphenoidal approach assisted by multiple techniques is the preferred surgical method for giant invasive pituitary adenomas invading cavernous sinus.The lateral cavernous sinus approach and the further molecular biology research will bring more options for the treatment of invasive pituitary adenomas.

Role of the superior turbinate when performing endoscopic endonasal transsphenoidal approach

This study examined the relationship between the superior turbinate and natural ostium of the sphenoid sinus, as seen during the endoscopic endonasal transsphenoidal approach (EETSA) for sellar lesions and described how to enter the sphenoethmoid cell safely for complete exposure of the sellar floor, including adjacent vital structures such as the prominence of the optic nerve and carotid artery. This study retrospectively reviewed the medical records and operative findings of 154 patients, who underwent EETSA between February 2009 and February 2011. We evaluated the location of the natural ostium of the sphenoid sinus relative to the superior turbinate and revealed the clinical significance of the superior turbinate as a surgical guide to enter into the sphenoethmoid cell during EETSA. The natural ostium of the sphenoid sinus was located medially to the posteroinferior end of the superior turbinate in 151 (98%) patients. In 1 patient, the natural ostia of the sphenoid sinus were located lateral to the superior turbinate bilaterally. Sphenoethmoid cell was encountered in 53 (34%) patients. We could easily enter the sphenoethmoid cell at the point where the superior turbinate was attached to the anterior wall of the sphenoid sinus. The superior turbinate is a good surgical landmark for identifying the natural ostium of the sphenoid sinus and as a guide for the surgical entrance to the sphenoethmoid cell extending to the sphenoid sinus during EETSA.

Sinusitis after Endoscopic Transsphenoidal Pituitary Surgery: Is Pre-Operative CT Imaging Predictive of Post-Operative Sinonasal Disease?

Objectives/Hypothesis: Endoscopic endonasal transsphenoidal approaches (TSAs) to sellar and parasellar tumors are generally well tolerated, however there are potential drawbacks with respect to post-operative sinonasal function. It has been observed that several patients who undergo this procedure ultimately require secondary sinus surgery. The objective of this study was to determine if radiographic anatomy of the paranasal sinuses is predictive of post-operative sinonasal disease in patients undergoing TSAs for sellar and parasellar tumors. Identification of potential risk factors would allow for the identification of a patient population who could benefit from more extensive pre-operative counseling, more frequent post-operative debridement, early initiation of medical therapy, or even endoscopic sinus surgery before/concomitant with pituitary surgery.

Transsphenoidal endoscopic endonasal approach for the surgery of pituitary abscess

To evaluate the effectiveness of transsphenoidal endoscopic endonasal approach for the surgery of pituitary abscess. Eighteen pathologically diagnosed pituitary abscess were resected through transsphenoidal endoscopic endonasal approach at Tianjing Huanhu hospital between January 2000 and December 2011.Retrospective analysis was done upon clinical presentations and imaging features. There were 6 males and 12 females. The average age was 48.5 years old and the average disease course was 5.8 years. The typical clinical manifestations included headache (13 cases), pituitary dysfunction (10 cases), Diabetes Insipidus (4 cases) visual interference (8 cases) and fever (4 cases). All cases were resected by transsphenoidal endoscopic endonasal approach with general anesthesia. The postoperative symptoms and follow-up results were recorded. All patients were followed up from 6 months to 6 years. Postoperatively, headache was recovered in 13 cases, visual was improved in 6 cases, hypopituitarism was relieved in 8 cases and polyuria was disappeared in 3 cases. One case was recurrent and cured by transsphenoidal endoscopic endonasal approach. Transsphenoidal endoscopic endonasal approach for the surgery of pituitary abscess is effective.

Analysis of the Bacterial Flora in the Nasal Cavity and the Sphenoid Sinus Mucosa in Patients Operated on with an Endoscopic Endonasal Transsphenoidal Approach

The aim of this study was to analyze the bacterial flora in the nasal cavity and sphenoid sinus and evaluate the sensitivity of these bacteria to antibiotics that can be used to prevent postoperative meningitis. Bacteria of the preoperative nasal cavity and intraoperative sphenoid sinus mucosa were cultured and analyzed in 40 patients (20 men and 20 women; mean age, 52.2 years) who underwent endoscopic transsphenoidal surgery. The sensitivity of these bacteria to cephalosporin, a representative prophylactic antibiotic, was examined. Staphylococcus epidermidis was the most frequently detected species in both spaces; 24 (38.7%) of 62 isolates in the nasal cavity and 26 (37.1%) of 70 isolates in the sphenoid sinus. In contrast, Corynebacterium species were found mainly in the nasal cavity, and anaerobic bacteria were found only in the sphenoid sinus. Bacteria that were resistant to cephalosporin were found in the nasal cavity in 3.2% of patients and in the sphenoid sinus in 20% of patients. In conclusion, the composition of bacterial flora, including bacteria that are resistant to prophylactic antibiotics, differs between the nasal cavity and the sphenoid sinus.

Endoscopic endonasal trans-sphenoidal management of cystic sellar lesions

Introduction The trans-sphenoidal route is now considered the standard approach for pituitary adenomas. This approach is increasingly safe with the use of endoscope. Aim of the study The aim of this study was to assess 11 patients with cystic sellar lesion operated by an endoscopic endonasal trans-sphenoidal approach. Patients and methods Between January 2007 and January 2011, 11 patients underwent standard endoscopic endonasal trans-sphenoidal surgery in the neurosurgical department, Tanta University, Egypt. All patients underwent complete clinical, endocrinological, and visual field evaluation before operation. The imaging study was performed by MRI of the sellar region with and without intravenous gadolinium contrast. Results The study included 11 patients: six female patients and five male patients, with a mean age of 34 years. The aim of the procedure for cystic lesion was to open the cyst cavity and remove a part of its wall through the sphenoid sinus and to remove the solid component if present. Conclusion The use of endoscopy in the treatment of cystic lesion is considered a very useful tool with its panoramic view that permits better exploration of the cystic cavity to assess the completeness of tumor removal.

Endoscopic endonasal transsphenoidal approach for sellar tumors beyond the sellar turcica

Conclusions: The endoscopic endonasal transsphenoidal approach can be a choice for sellar tumors beyond the sellar turcica, but it is necessary to make the choice carefully because of the severe surgical risks. Objectives: To summarize our experience of removal of sellar tumors beyond the sellar turcica via the endoscopic endonasal transsphenoidal approach and to evaluate the surgical efficacy and complications. Methods: Between January 2007 and January 2012, 30 patients with sellar tumors beyond the sellar turcica underwent surgery using the endoscopic endonasal transsphenoidal approach. Results: Postoperative pathological examination demonstrated that pituitary adenoma occurred in 22 patients, craniopharyngioma in 5, and meningioma in 3. Total removal was achieved in 21 patients (70.0%) and subtotal removal was achieved in 8 patients (26.7%). After the surgery, cerebrospinal fluid leakage occurred in 3 patients, temporary diabetes insipidus occurred in 25 patients and persistent diabetes insipidus in 4 patients, intracranial infection occurred in 1 patient, frontal subdural effusion occurred in 1 patient, sinusitis occurred in 2 patients, epistaxis occurred in 3 patients, and 1 patient with a huge pituitary adenoma died of hypothalamic failure related to the operation.

Erratum to: Endoscopic endonasal trans-sphenoidal approach for pituitary adenomas: Is one nostril enough?

The original version of this article unfortunately contained mistakes. On page 1607 and 1608, the figure legends for Fig 5 and 6 should be interchanged. Figure 5 shows images obtained from a 64-year-old female with a nonfunctioning macroadenoma who underwent the two-nostril approach. Figure 6 comprises images obtained from a 51-year-old man with a GH-secretingmacroadenomawho underwent the one-nostril approach.

Surgical management of pituicytomas: case series and comprehensive literature review

Pituicytomas are rare neoplasms that typically present as solid, noninfiltrative tumors occupying the sella and/or suprasellar space for which there is no consensus on optimal surgical management. We aimed to define a preferred surgical strategy for these tumors based on our clinical experience and comprehensive review of the world literature. Case series and review of the literature. We documented the clinical, radiographic, and surgical findings of three patients with pituicytoma treated at our institution, as well as complications and long-term outcomes. A comprehensive review of the medical literature identified all cases of pituicytoma for which data regarding surgical approach, outcome and complications could be extracted. We compared our results with published data. All three cases at our institution achieved gross total removal. Two patients underwent an expanded endoscopic endonasal transsphenoidal and transplanum (EETS-TP) approach, while one tumor was removed via craniotomy. Post-operatively all patients developed pan-hypopitutarism. The patient undergoing craniotomy suffered profound visual loss but no other neurological complications were noted. A literature review identified 67 reported cases of pituicytoma. Surgical data was available in 60 cases. Surgical approach was documented in 57 patients. Sixty-three surgeries were performed in which approach and extent of resection was available. Gross total removal was obtained in 33 % of craniotomies, 42 % of transsphenoidal procedures, and 100 % of expanded transsphenoidal procedures. Neurological complications including visual loss, hemiparesis and cranial nerve palsies were reported after craniotomy, but not after transsphenoidal approaches. Overall EETS-TP approaches were associated with the highest rate of gross total removal and no visual or neurological complications. EETS-TP surgery is the preferred strategy for surgical removal of pituicytoma. EETS-TP and transsphenoidal approaches are associated with higher rates of gross total removal and lower rates of neurological complications than craniotomy. Gross total removal should be the intended goal of surgery.

Bilateral Nasoseptal Flaps for Endoscopic Endonasal Transsphenoidal Approach

A nasoseptal flap is used to reconstruct defects in the skull base when cerebrospinal fluid (CSF) leaks after the endoscopic endonasal transsphenoidal approach (EETSA). We evaluated the usefulness of elevating bilateral nasoseptal flaps with the EETSA. Sixty-seven patients (71 procedures, including 4 revisions) underwent the EETSA with bilateral nasoseptal flap elevation. We retrospectively reviewed patients' medical records, including demographic data, surgical procedures, outcomes, and complications. The entire sellar floor was exposed after elevating bilateral nasoseptal flaps. We reconstructed the defect using a right nasoseptal flap in 14 cases with intraoperative CSF leakage. The denuded sphenoidal sinus was covered with a left nasoseptal flap in 13 cases with excessive loss of sphenoidal sinus mucosa. Unused flaps (57 right flaps and 58 left flaps) were repositioned in the original sites. No postoperative CSF leak occurred. All sphenoidal sinuses covered with the left nasoseptal flap healed well without excessive crust. Two patients experienced immediate postoperative bleeding. Septal perforation occurred in 1 patient who underwent a revision operation. Bilateral nasoseptal flap elevation provided good exposure of the sellar floor with the EETSA. The nasoseptal flap could be used to reconstruct the defect after the EETSA and to cover the denuded sphenoidal sinus. The unused flaps could be repositioned in their original sites to minimize the septal defect and could be reused in revision surgery. We suggest that elevating bilateral nasoseptal flaps is a useful surgical technique in a variety of settings with the EETSA.