Endoscopic Transsphenoidal Pituitary Surgery Research Articles

Three-Dimensional High-Definition Neuroendoscopic Surgery: A Controlled Comparative Laboratory Study with Two-Dimensional Endoscopy and Clinical Application

The purpose of this research was to investigate the usefulness of three-dimensional (3D) endoscopy compared with two-dimensional (2D) endoscopy in neuroendoscopic surgeries in a comparative study and to test the clinical applications. Forty-three examinees were divided into three groups according to their endoscopic experience: novice, beginner, or expert. Examinees performed three separate tasks using 3D and 2D endoscopy. A recently developed 3D high-definition (HD) neuroendoscope, 4.7 mm in diameter (Shinko Optical Co., Ltd., Tokyo, Japan) was used. In one of the three tasks, we developed a full-sized skull model of acrylic-based plastic using a 3D printer and a patient's thin slice computed tomography data, and evaluated the execution time and total path length of the tip of the pointer using an optical tracking system. Sixteen patients underwent endoscopic transnasal transsphenoidal pituitary surgery using both 3D and 2D endoscopy. Horizontal motion was evaluated using task 1, and anteroposterior motion was evaluated with task 3. Execution time and total path length in task 3 using the 3D system in both novice and beginner groups were significantly shorter than with the 2D system (p < 0.05), although no significant difference between 2D and 3D systems in task 1 was seen. In both the novice and beginner groups, the 3D system was better for depth perception than horizontal motion. No difference was seen in the expert group in this regard. The 3D HD endoscope was used for the pituitary surgery and was found very useful to identify the spatial relationship of carotid arteries and bony structures. The use of a 3D neuroendoscope improved depth perception and task performance. Our results suggest that 3D endoscopes could shorten the learning curve of young neurosurgeons and play an important role in both general surgery and neurosurgery.

Endonasal endoscopic transsphenoidal pituitary surgery: early experience and outcome in paediatric Cushing's disease

Selective adenomectomy remains the first-line treatment for Cushing's disease (CD), until recently by microscopic transsphenoidal pituitary surgery. Endonasal transsphenoidal endoscopic surgery (ETES) is emerging as a novel, less invasive treatment for pituitary adenomas and has become the optimal surgical approach. There are no published series for the treatment of paediatric CD by ETES, and we report our centre's preliminary results. Retrospective analysis. Six paediatric patients (median age 15·8 years; range 11·7-17·0 years) fulfilled standard diagnostic criteria for CD. Preoperatively, no abnormality was identified on pituitary MR scanning in 3 (50%) patients, one had a macroadenoma. Bilateral petrosal sinus sampling demonstrated central ACTH secretion (IPS/P ACTH ratio ≥3·0, post-CRH) in 3/6 (50%) patients. The same neurosurgeon and endoscopic nasal surgeon undertook all the operations. Therapeutic outcome and rate of complications. Clinical recovery and biochemical 'cure' were achieved in 5 (83%) patients, and a corticotroph adenoma was confirmed histologically in all cured cases. One case developed post-operative CSF leak requiring lumbar drain insertion and patching. At a mean interval of 4·7 years (0·1-10·8 years) post-operatively, cured patients have shown no recurrence. One patient, with a large diffuse adenoma requiring more extensive surgery, has panhypopituitarism, and another patient has GH and gonadotrophin deficiencies. Our experience shows that ETES for removing corticotroph adenomas in children, in most cases not visualized on MRI, is minimally invasive and gave excellent post-operative recovery/results. In skilled hands, this technique provides an alternative to conventional transsphenoidal microscopic surgery in managing paediatric CD.

The learning curve of endoscopic transsphenoidal pituitary surgery

Objective To investigate the learning curve of endoscopic transsphenoidal pituitary surgery by comparing the effects of endoscopic transsphenoidal pituitary surgery at different stages.Methods From September 2002 to December 2006,180 patients undergoing endoscopic transsphenoidal pituitary surgery,performed by a single team,were retrospectively evaluated.The patients were divided into groups A to C (n =60) based on the surgery data; operation time,intraoperation blood loss,conversion to microsurgery,total removal,improvement of postoperative vision,complications,and postoperative hospital stay were compared Results No statistical differences were found among the group in age,gender,turnor size,and pathological type; the significant differences were found in the operation time between group A,B,andC (P ＜0.05),but the operation time in group A was significantly longer than that in groups B and C (P ＜0.05).Compared with that in group A,the number of conversion to microsurgery decreased significantly in groups B and C.2 patients in group B and another in group C developed severe postoperative complications.The intraoperation blood loss,total removal,postoperative vision,complications,and postoperative hospital stay showed no differences amongst the three groups.Conclusions Endoscopic transsphenoidal pituitary surgery needs a minimum case-load of 60 patients to help go beyond the steep phase of the learning curve. Key words: Endoscope; Pituitary adenoma; Endonasal transsphenoidal surgery; Learning curve

Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas

Although the endoscopic technique of transsphenoidal pituitary surgery (TS) has been widely adopted, reports on its results in Cushing's disease (CD) are still scarce and no studies have investigated long-term recurrence rates. This is the largest endoscopic series published till now. To gain insight into the role of endoscopic TS as a primary treatment option for CD, especially in patients with magnetic resonance imaging (MRI)-negative CD and (invasive) macroadenomas. Retrospective cohort study. The medical records of 86 patients with CD who underwent endoscopic TS were examined. Data on preoperative and postoperative evaluation, perioperative complications, and follow-up were collected. Remission was defined as disappearance of clinical symptoms with a fasting plasma cortisol level ≤ 50 nmol/l either basal or after 1 mg dexamethasone. The remission rate in different adenoma subclasses varied significantly: 60% in MRI-negative CD (n=20), 83% in microadenomas (n=35), 94% in noninvasive macroadenomas (n=16), and 40% in macroadenomas that invaded the cavernous sinus (n=15). The recurrence rate was 16% after 71 ± 39 months of follow-up (mean ± S.D., range 10-165 months). Endoscopic TS is a safe and effective treatment for all patients with CD. Recurrence rates after endoscopic TS are comparable with those reported for microscopic TS. Our data suggest that in patients with noninvasive and invasive macroadenomas, the endoscopic technique of TS should be the treatment of choice as remission rates seem to be higher than those reported for microscopic TS, although no comparative study has been performed.

Endoscopic distinction between capsule and pseudocapsule of pituitary adenomas

Pseudocapsules were first identified in pituitary adenoma surgery in 1936. Since then, the distinction between pituitary capsules and pseudocapsules has been unclear, and the definitions of these entities have varied. In this study, pituitary capsules and extracapsular dissection were examined retrospectively, intra- and extrapseudocapsular resection was evaluated, and dissection of the pituitary adenoma and pseudocapsule was examined prospectively. Between January 2009 and May 2012, endoscopic transsphenoidal pituitary surgery was performed on 224 patients in the Department of Neurosurgery, Kocaeli University Faculty of Medicine, Turkey. Data for 174 patients were analyzed retrospectively between January 2009 and December 2011, and 50 patients treated between December 2011 and May 2012 were included in a prospective study. In the retrospective phase of the study, capsules were examined in 21 of the 174 patients on whom extracapsular resection had been performed. In the 50 cases treated between December 2011 and May 2012, dissection of the pituitary capsule, adenohypophysis, and pseudocapsule was performed. In 30 patients in the prospective phase of the study, pseudocapsules were identified during intraoperative endoscopic observation. Remission was achieved in 28 of 33 functioning adenomas in the prospective study. The mean follow-up period in this group was 13 months. The endoscopic and histopathological evidence provided in this study demonstrates that the pituitary capsule and pseudocapsule are distinct structures. In addition, it is also shown that extracapsular dissection can be performed in functioning adenomas that invade the suprasellar region. Significantly higher rates of total resection and higher remission rates were observed in cases where extra- and intrapseudocapsular dissection was required.

Observation of the neurohypophysis, pituitary stalk, and adenohypophysis during endoscopic pituitary surgery: Demonstrative findings as clues to pituitary-conserving surgery

High-definition imaging in endoscopic transsphenoidal pituitary surgery accounts for significantly better identification of anatomic structures. This report presents the clinical images of the adenohypophysis and neurohypophysis under high-definition endoscopic observation, and provides some clues for pituitary-sparing surgery. Ten demonstrative cases of pituitary lesions, including three cases of gonadotropin-producing pituitary adenoma, two cases of somatotropin-secreting pituitary adenoma, and five cases of Rathke's cleft cysts, were entered in this study. From these cases, we extracted helpful intraoperative findings that affected the surgeon's decision about surgical procedures and led to favorable results. The extracted findings contain the following lessons: (1) to find a boundary plane that separate a lesion from the pituitary; (2) to mark the difference of color between the adenohypophysis and the neurohypophysis; (3) to identify the location of the pituitary stalk connecting to the neurohypophysis; (4) to observe the color change of the pituitary induced by decompression; (5) to know pathological findings of the pituitary surface; (6) to distinguish the parenchyma of the neurohypophysis from pathological tissues; and (7) to recognize the intrasellar findings at the completion of removal. Recognition of these findings led to an excellent result in each case. Despite being shown in a limited number of cases, on the basis of HD endoscopic images, accurate identification of the neurohypophysis and the pituitary stalk as well as adenohypophysis during surgery contributes to pituitary-conserving operations.

Clinical and histologic studies of olfactory outcomes after nasoseptal flap harvesting

Since the introduction of an endonasal endoscopic approach in transsphenoidal pituitary surgery, reports of perioperative olfactory changes have presented conflicting results. We examined the incidence of olfactory loss in cases of endoscopic transsphenoidal pituitary surgery with skull base repair using the nasoseptal flap (NSF) and the effects of monopolar electrocautery commonly used in designing the NSF. Case-control study. Fifteen patients who underwent endoscopic transsphenoidal pituitary surgery with skull base reconstruction using the NSF were divided into cold knife (n = 8) and electrocautery (n = 7) groups according to the device used in the superior incision of the NSF. Patients were followed regularly to monitor the need for dressing or adhesiolysis around the olfactory cleft. All subjects received olfactory tests before and 6 months after surgery. Septal mucosa specimens obtained during posterior septectomy were incised with different devices, and the degree of mucosal damage was evaluated. One patient in the electrocautery group demonstrated olfactory dysfunction postoperatively, but the other 14 patients showed no decrease in olfaction. In histologic analyses, 55.8% and 76.9% of the mucosal surface showed total epithelial loss when the mucosa was cut with cutting- and coagulation-mode electrocautery, respectively. In contrast, only 20% of the mucosal surface exhibited total epithelial loss when the mucosa was cut with a cold knife (P < .01). Olfactory impairment is not common after use of the NSF. Use of the cold knife in making superior incision may reduce tissue damage with better olfactory outcomes.

Endoscopic Transsphenoidal Pituitary Surgery: Result, Safety, and Cost Effectiveness in 134 Consecutive Cases

Objective: Pituitary surgery is being performed increasingly using an endoscopic transsphenoidal approach. Here, we report a series of patients undergoing pituitary surgery using an endoscopic transsphenoidal approach and evaluate the safety, cost effectiveness, and short-term outcomes of this procedure.

Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve

Endoscopic transsphenoidal surgery for pituitary adenomas has been introduced as an alternative to transsphenoidal microsurgery. This is the first Australian study to evaluate a single surgeon's experience by comparing our results with other series and attempting to identify a learning curve. Retrospective analysis was carried out on 79 consecutively treated patients by fully endoscopic transsphenoidal surgery by a single neurosurgeon over a period spanning from July 1998 to September 2010 at St George Public and Private hospitals. The mean age at time of surgery was 56.7 years (SD ± 16.3, range 26–85) and the mean follow-up period was 38.2 months (SD ± 33, range 1–136). Gross total resection (GTR) was noted in 63% of patients, endocrinological cure was achieved in 53% and visual field improvements were noted in 86% of patients. Intra-operative CSF leaks occurred in 19% of procedures, while the rates of post-operative CSF rhinorrhea was 3% and post-operative diabetes insipidus was 13%. There was one post-operative death (1%). Compared to microsurgery, intra-operative CSF leaks and meningitis seem less frequent with an endoscopic approach. With increasing experience, we found a non-statistically significant trend towards higher rates of GTR, and improved visual fields. Endocrinological cure rates were clearly better with experience (p < 0.01). There may be a learning curve that can be overcome in 30–40 cases. Endoscopic transsphenoidal surgery provides similar tumour and patient outcomes when compared to transsphenoidal microsurgery. In this single surgeon's experience, there was a trend to indicate improved performance with more case experience.

A prospective qualitative study on patients’ perceptions of endoscopic endonasal transsphenoidal surgery

Background. Endoscopic transsphenoidal surgery has been shown to be a safe and effective treatment option for patients with pituitary tumours, but no study has explored patients’ perceptions before and after this surgery. Objective. The authors in this study aim to explore patients’ perceptions on endoscopic transsphenoidal surgery. Methods. Using qualitative research methodology, two semi-structured interviews were conducted with 30 participants who were adults aged > 18 undergoing endoscopic transsphenoidal surgery for the resection of a pituitary tumour between December 2008 and June 2011. The interviews were audiotaped and transcribed. The resulting data was analyzed using a modified thematic analysis. Results. Seven overarching themes were identified: (1) Patients had a positive surgical experience; (2) patients were satisfied with the results of the procedure; (3) patients were initially surprised that neurosurgery could be performed endonasally; (4) patients expected a cure and to feel better after the surgery; (5) many patients feared that something might go wrong during the surgery; (6) patients were psychologically prepared for the surgery; (7) most patients reported receiving adequate pre-op and post-op information. Conclusions. This is the first qualitative study reporting on patients’ perceptions before and after an endoscopic endonasal transsphenoidal pituitary surgery, which is increasingly used as a standard surgical approach for patients with pituitary tumours. Patients report a positive perception and general satisfaction with the endoscopic transsphenoidal surgical experience. However, there is still room for improvement in post-surgical care. Overall, patients’ perceptions can help improve the delivery of comprehensive care to future patients undergoing pituitary tumour surgery.

Comparison of endoscopic and microscopic trans-sphenoidal pituitary surgery: early results in a single centre

Introduction. Pituitary surgery has seen a recent shift from a microscopic to an endoscopic trans-sphenoidal approach. We present our early experience with endoscopic surgery and compare the outcome with our recent microscopic experience. Methods. From January 2008 until present time, 80 consecutive patients underwent trans-sphenoidal pituitary surgery in our institution. Until September 2009, all patients had a microscopic trans-septal approach. After this time, the patients underwent endoscopic trans-sphenoidal surgery. All patients underwent pre- and post-operative MRI and full endocrinological evaluation. Data was collected prospectively including tumour volume, endocrine function, visual function, length of stay and complications. Results. There were 40 patients in each group. In the microscopic group, there were 26 non-functioning tumours and 14 functioning tumours. In the endoscopic group, there were 24 non-functioning and 16 functioning tumours. There were significantly better results in terms of tumour resection (p = 0.002) and remission (p = 0.018) in the endoscopic group. In this group there was also a lower incidence of CSF leaks and a shorter length of stay for secreting tumours (p = 0.005). 1 patient in the endoscopic group died at day 43 post-operatively, having initially presented in a poor clinical state with pituitary apoplexy. Conclusion. Microscopic trans-sphenoidal surgery remains the benchmark for future surgical techniques. Our early results suggest that endoscopic trans-sphenoidal surgery provides favourable results in both tumour resection and control of secreting tumours in comparison with microscopic surgery. Further longer-term evaluation is required to ensure the outcome of endoscopic surgery.

Clinical implications of rhinosinusitis detected by preoperative computed tomography for endoscopic endonasal transsphenoidal pituitary surgery

Conclusions: Rhinosinusitis detected by preoperative osteomeatal unit computed tomography (OMU CT) may not increase the incidence of postoperative central nervous system (CNS) infections. Objectives: To evaluate the safety of endoscopic endonasal transsphenoidal pituitary surgery in patients who had rhinosinusitis detected by preoperative OMU CT. Methods: A total of 107 patients who underwent endoscopic endonasal transsphenoidal pituitary surgery were enrolled. The presence of rhinosinusitis and the location of involved sinuses were assessed by preoperative OMU CT. The extent of pituitary tumors was assessed by preoperative sellar MRI. The occurrence of intraoperative cerebrospinal fluid (CSF) leakage and postoperative central nervous system (CNS) complications were analyzed using the medical records. The correlations between these variables and postoperative CNS complications were examined. Results: After pituitary surgery, postoperative CNS complications occurred in four patients (3.7%). Twenty-eight patients (26.2%) had findings of rhinosinusitis on preoperative OMU CT. Of the 28 patients, 8 had rhinosinusitis in the anterior sinuses and 20 in the posterior sinuses. Intraoperative CSF leakage occurred in eight patients (7.5%). The occurrence of intraoperative CSF leakage showed a significant correlation with the incidence of postoperative CNS complications (p = 0.003) but not with the presence of rhinosinusitis (p = 0.134). Although not statistically significant, patients with rhinosinusitis in the posterior ethmoidal and/or sphenoidal sinuses tended to have higher incidences of postoperative CNS complications (p = 0.057).

Low-Grade CSF Leaks in Endoscopic Transsphenoidal Pituitary Surgery: Efficacy of a Simple and Fully Synthetic Repair with a Hydrogel Sealant

Low-Grade CSF Leaks in Endoscopic Transsphenoidal Pituitary Surgery: Efficacy of a Simple and Fully Synthetic Repair with a Hydrogel Sealant

Application of Computed Tomography Virtual Endoscopy in Endoscopic Transsphenoidal Pituitary Surgery

Application of Computed Tomography Virtual Endoscopy in Endoscopic Transsphenoidal Pituitary Surgery

Application of computed tomography virtual endoscopy in endoscopic transsphenoidal pituitary surgery

Objective To valuate the application of computed tomography virtual endoscopy (CTVE) for endoscopic transsphenoidal pituitary surgery.Method The CTVE was applied to a series of 38 patients with pituitary adenomas operated endoscopically via the transsphenoidal approach at the Wuxi Second Hospital Affiliated Nanjing Medical University between September 2010 and June 2011.Results CTVE can be applied to simulate the endoscopic endonasal transsphenoidal pituitary surgery,and indicate the anantomic structure through the endonasal transsphenoidal approach.CTVE can preoperatively assess the morphological images of the nasal,sphenoid sinus,sellar floor and around structure,which correlated well with the intraoperative endoscopic view.The degree of pneumatization of the sphenoid sinus,the size of the sella and the sept conditions may influence the application of CTVE.Conclusions CTVE can not only act as a training simulator for the endoscopic transsphenoidal pituitary surgery,but for the experienced surgeon,it can depict the individual patient's anatomical landmarks and variations,what may help make preoperative planning and increase the safety of the endoscopic endonasal transsphenoidal pituitary surgery. Key words: Neuroendoscopy; Pituitary adenoma; Virtual endoscopy; Endonasal transsphenoidal surgery

Minimizing Intraoperative CSF Leaks in Endonasal Endoscopic Transsphenoidal Pituitary Surgery: Technical Considerations and Case Series Review

Minimizing Intraoperative CSF Leaks in Endonasal Endoscopic Transsphenoidal Pituitary Surgery: Technical Considerations and Case Series Review

内視鏡下経蝶形骨洞下垂体腫瘍切除術中の心静止症例

内視鏡下経蝶形骨洞下垂体腫瘍切除術中の心静止症例

Comparison of traditional 2‐dimensional endoscopic pituitary surgery with new 3‐dimensional endoscopic technology: intraoperative and early postoperative factors

Traditionally, endoscopic transsphenoidal pituitary surgery is performed using 2-dimensional (2D) endoscopes, which lack depth of field and contribute to image distortion. Recently, a new generation of 3D endoscopes has been introduced for improved endoscopic depth perception. Little data exist comparing surgical outcomes with 2D vs 3D endoscopic systems. This study examines perioperative and postoperative factors in patients undergoing pituitary surgery using 2D vs 3D endoscopes. The objective of this work was to determine the differences in perioperative and postoperative factors in patients undergoing pituitary surgery using 2D vs 3D endoscopy. Retrospective chart review at a tertiary academic referral center. Statistical comparison was undertaken for perioperative (estimated blood loss, operative time) and postoperative factors (length of stay, complications, and readmission rate). A total of 58 patients underwent endoscopic pituitary surgery during the 24-month study period (22 functional, 36 nonfunctional lesions). The 2D endoscopic system was used for pituitary tumor resection in 32 patients (55%), and the 3D endoscopic system in 26 patients (45%). No significant difference existed between 2D and 3D endoscopic systems for operative time (p = 0.275) or estimated blood loss (p = 0.312). Additionally, no difference was found between groups for cerebrospinal fluid (CSF) leak rate (p = 0.581), postoperative endocrine complications (p = 0.081), length of hospital stay (p = 0.934), or hospital readmission rate (p = 1.0). 3D endoscopy affords the surgeon improved depth of field and stereoscopic vision. Our data demonstrate that 3D endoscopy does not result in significantly different perioperative or postoperative outcomes vs 2D endoscopic surgery.

Pituitary metastasis from adenocarcinoma

. CASE A 50-year-old male patient sought medical care com -plaining of cephalalgia for 4 months, diplopia and ptosis of the left eyelid for 30 days. He reported loss of libido and erectile dysfunction in the previous six months. He was before a salutary individual. Physical examination: body mass index (BMI) 24, with ptosis and ophthalmo-plegia of the left eye, arterial pressure of 140/80 mmHg. No other alterations. Magnetic resonance imaging (Figure) showed hetero -geneous mass into the sella turcica with suprasellar ex-tension, causing displacement of optic chiasm and third ventricle floor, with intense opacification after contrast.The laboratory exams showed normal thyroid func-tion, low levels of gonadotropins and total testosterone, normal levels of basal cortisol and IGF-1 and very small increase in serum prolactin. Renal function, serum so-dium and urine density were within normal limits. Cen -tral hypogonadism and slight hyperprolactinemia were de -tected, without evidence of posterior pituitary alteration. An endoscopic transsphenoidal pituitary surgery were performed and anatomopathological exam showed metastasis of moderately differentiated adenocarcinoma of unknown primary site. Postoperative exams showed anemia, increased GGt, FA and CA 19-9. Immunohisto -chemical analysis indicated origin in the gastrointestinal tract, imaging of thorax and abdomen showed lymphade -nopathies and small irregularities on the antral mucosa wall of the stomach. Upper gastrointestinal endoscopy with biopsy showed stomach antral adenocarcinoma.DISCUSSIONMetastatic tumors of the pituitary gland are rare complications

Olfactory outcomes after endoscopic transsphenoidal pituitary surgery

Olfaction has been demonstrated to have a great impact on patients' lives. Transsphenoidal endoscopic pituitary surgery is associated with potentially significant damage to olfactory tissues, but to date this issue has been only poorly documented in the literature. Prospective cohort study comparing olfactory outcomes pre- and postpituitary surgery. Patients were administered the University of Pennsylvania Smell Identification Test (UPSIT) preoperatively and again at 6 months postoperatively. The endoscopic transsphenoidal pituitary surgery was carried out using a full middle turbinate preservation protocol. A Hadad-Bassagasteguy (HB) vascularized septal flap was raised in each case. Secondary outcomes included Lund-Kennedy endoscopy scores (LKES) and patient self-report of olfactory disturbance. The results were analysed using a paired t-tests. Seventeen patients met inclusion criteria for the study. Mean preoperative UPSIT value was 37.2 (normosmia), and mean postoperative UPSIT value was 30.8 (moderate hyposmia) (P < .001). All patients were fully healed with normal LKES scores by 6 months. All patients complained of their olfactory dysfunction. This study is the first to describe postoperative olfactory perturbations suffered by patients undergoing endoscopic transsphenoidal pituitary surgery. We hypothesize that olfactory impairment results from use of the HB flap. We recommend that the possibility of permanent olfactory changes be added to routine patient counseling and consent for this procedure, and that HB flaps be raised judiciously during trannssphenoidal endoscopic procedures.