Transsphenoidal Surgery For Pituitary Lesions Research Articles

Serum Prolactin Level to Tumor Size Ratio as a Potential Parameter for Preoperative Differentiation of Prolactinomas from Hyperprolactinemia-Causing Non-functional Pituitary Adenomas

Preoperative diagnosis of prolactinomas is critical because dopamine agonists have been regarded as a primary treatment. However, serum prolactin level alone is suboptimal for differentiating prolactinomas from hyperprolactinemia-causing non-functioning pituitary adenomas (NFPAs). By using the tumor size, the authors tried to investigate an effective parameter for the discrimination. We performed a retrospective review of patients who underwent trans-sphenoidal surgery for pituitary lesions in a single institute between January 2015 and May 2021. Using receiver operating curve (ROC) analyses, we compared performances of serum prolactin levels (PRL), a ratio of serum PRL levels to maximal tumor diameter (MD) (PRL/MD; PDR1), and MD squared (PRL/[MD]2; PDR2) in preoperative diagnosis of prolactinomas. A total of 223 patients with NFPAs (n= 175) and prolactinomas (n= 48) were included in the analysis. A moderate correlation was found between serum prolactin levels and MDs in prolactinomas (Pearson's rprl= 0.43, P= 0.002), whereas a weak correlation was observed in NFPAs (Pearson's rnfpa= 0.17, P= 0.028). Among diagnostic parameters, PDR2 exhibited the optimal diagnostic performance with the cutoff value of 0.83 [㎍/L]/mm2 (area under the curve [AUC]= 0.945), compared with the PDR1 (8.93 [㎍/L]/mm with AUC 0.938) and PRL (99.4 ㎍/L with AUC 0.910). In the external validation study, PDR2 maintained superior performance over PDR1 and PRL (accuracy of 94.8%, 91.8%, and 75.8%, respectively). PDR2 was a more effective indicator than prolactin alone in the preoperative differential diagnosis of prolactinomas and NFPAs, which may help select patients who need medical treatment first.

Feasibility of machine learning based predictive modelling of postoperative hyponatremia after pituitary surgery.

Hyponatremia after pituitary surgery is a frequent finding with potential severe complications and the most common cause for readmission. Several studies have found parameters associated with postoperative hyponatremia, but no reliable specific predictor was described yet. This pilot study evaluates the feasibility of machine learning (ML) algorithms to predict postoperative hyponatremia after resection of pituitary lesions. Retrospective screening of a prospective registry of patients who underwent transsphenoidal surgery for pituitary lesions. Hyponatremia within 30days after surgery was the primary outcome. Several pre- and intraoperative clinical, procedural and laboratory features were selected to train different ML algorithms. Trained models were compared using common performance metrics. Final model was internally validated on the testing dataset. From 207 patients included in the study, 44 (22%) showed a hyponatremia within 30days postoperatively. Hyponatremic measurements peaked directly postoperatively (day 0-1) and around day 7. Bootstrapped performance metrics of different trained ML-models showed largest area under the receiver operating characteristic curve (AUROC) for the boosted generalized linear model (67.1%), followed by the Naïve Bayes classifier (64.6%). The discriminative capability of the final model was assessed by predicting on unseen dataset. Large AUROC (84.3%; 67.0-96.4), sensitivity (81.8%) and specificity (77.5%) with an overall accuracy of 78.4% (66.7-88.2) was reached. Our trained ML-model was able to learn the complex risk factor interactions and showed a high discriminative capability on unseen patient data. In conclusion, ML-methods can predict postoperative hyponatremia and thus potentially reduce morbidity and improve patient safety.

National trends in hospital readmission following transsphenoidal surgery for pituitary lesions.

Several institutions recently published their experiences with unplanned readmissions rates after transsphenoidal surgery for pituitary lesions. Readmission rates on a national level, however, have not been explored in depth. We investigated nationwide trends in this procedure and associated independent predictors, costs, and causes of 30-day readmission. The Nationwide Readmissions Database was queried to identify patients 18 and older who underwent transsphenoidal surgery for pituitary lesion resection (2010-2015). National trends and statistical variances were calculated based on weighted, clustered, and stratified sample means. Of the weighted total of 44,759 patients treated over the 6-year period, 4658 (10.4%) were readmitted within 30days. Readmission rates did not change across the survey period (P = 0.71). Patients readmitted had a higher prevalence of comorbidities than those not readmitted (82.5% vs. 78.4%, respectively, P < 0.001), experienced more postoperative complications (47.2% vs. 31.8%, P < 0.001), and had a longer length of stay (6.59 vs. 4.23days, P < 0.001) during index admission. The most common causes for readmission were SIADH (17.5%) and other hyponatremia (16.4%). Average total readmission cost was $12,080 with no significant trend across the study period (P = 0.25). Predictors for readmission identified included diabetes mellitus, psychological disorders, renal failure, and experiencing diabetes insipidus during the index admission. Unplanned readmission is an important quality metric. While transsphenoidal pituitary surgery is a relatively safe procedure, 30-day readmission rates and costs have not declined. Future studies on institutional protocols targeting these identified predictors to prevent readmission are necessary to decrease readmission rates on a national scale.

Endoscopic endonasal transsphenoidal surgery: predictors for disease control in a consecutive series of pituitary adenomas

Abstract Endoscopic endonasal transsphenoidal surgery for pituitary lesions has been predestined and evolved since its incipient description. However, tumour size and extrasellar extensions of pituitary adenomas remain a challenge for disease control (DC) after surgery. This study was conducted to evaluate the predictors that determine the early outcome in a consecutive series of pituitary adenomas operated using an endoscopic transsphenoidal approach. Sixty-five consecutive pituitary adenomas presenting over a 36-month period subjected to excision through an entirely endoscopic transsphenoidal approach were reviewed. DC, based on the extent of tumour resection and endocrinological remission, was evaluated according to the recent radiological and hormonal consensus criteria. Of 65 pituitary adenomas operated, 24 were endocrinally nonfunctioning and 41 were functioning adenomas. The follow-up duration ranged from 3 to 33 months. The overall DC was 67.7% as measured using total tumour resection and endocrinal cure. Cavernous sinus invasion, suprasellar extension and revision surgery negatively influenced DC of pituitary adenomas. Postoperative complications related to surgical resection of adenomas were seen in 12 cases (18.5%) − mainly, cerebrospinal fluid leakage, anterior pituitary insufficiency, and diabetes insipidus. This study reports standards for DC in a short follow-up series of purely endoscopic pituitary surgeries and identifies pituitary lesions associated with preoperative predictors that can influence postoperative outcome. These results authenticate the efficacy and safety of endoscopic endonasal transsphenoidal surgery in the treatment of pituitary adenomas, providing favourable DC for both functioning and nonfunctioning pituitary adenomas.

Delayed Hyponatremia Is the Most Common Cause of 30-Day Unplanned Readmission After Transsphenoidal Surgery for Pituitary Tumors.

Unplanned readmission after surgical procedures is an important quality metric. Yet, readmission rates and causes have not been evaluated for patients after transsphenoidal surgery for pituitary tumors. To analyze unplanned 30-day readmissions at a pituitary center and to encourage the development of effective clinical pathways to prevent readmission. A retrospective review of adult patients who underwent transsphenoidal surgery for pituitary lesions at Barrow Neurological Institute (January 2011-March 2014) was performed to identify causes of unplanned readmission within 30 days of surgery. Patient demographics, tumor details, surgical complications, and endocrine function were documented. Of 303 patients who had transsphenoidal surgery, 27 (8.9%) were readmitted within 30 days. Most of the 27 (15 [55.6%]) had delayed hyponatremia. Other causes were diabetes insipidus (4 [14.8%]), adrenal insufficiency (2 [7.4%]), and cerebrospinal fluid leak, epistaxis, cardiac arrhythmia, pneumonia, urinary tract infection, and hypoglycemia (1 each [3.7%]). Outpatient sodium screening was performed as needed. In cases of hyponatremia, the mean postoperative day of readmission was day 8 (range, 6-12 days) and the mean serum sodium was 119 mmol/L (range, 111-129 mmol/L). Numerous patient and surgical factors were examined, and no specific predictors of readmission were identified. We developed an outpatient care pathway for managing hyponatremia with the goal of improving readmission rates. This study establishes a quality benchmark for readmission rates after transsphenoidal surgery for pituitary lesions and identifies delayed hyponatremia as the primary cause. Implementation of an outpatient care pathway for managing hyponatremia may improve readmission rates.

Predictors of sinonasal quality of life and nasal morbidity after fully endoscopic transsphenoidal surgery.

Despite the increasing application of endoscopic transsphenoidal surgery for pituitary lesions, the prognostic factors that are associated with sinonasal quality of life (QOL) and nasal morbidity are not well understood. The authors examine the predictors of sinonasal QOL and nasal morbidity in patients undergoing fully endoscopic transsphenoidal surgery. An exploratory post hoc analysis was conducted of patients who underwent endoscopic pituitary surgery and were enrolled in a prospective multicenter QOL study. End points of the study included patient-reported sinonasal QOL and objective nasal endoscopy findings. Multivariate models were developed to determine the patient and surgical factors that correlated with QOL at 2 weeks through 6 months after surgery. This study is a retrospective review of a subgroup of patients studied in the clinical trial "Rhinological Outcomes in Endonasal Pituitary Surgery" (clinical trial no. NCT01504399, clinicaltrials.gov ). Data from 100 patients who underwent fully endoscopic transsphenoidal surgery were included. Predictors of a lower postoperative sinonasal QOL at 2 weeks were use of nasal splints (p = 0.039) and female sex at the trend level (p = 0.061); at 3 months, predictors of lower QOL were the presence of sinusitis (p = 0.025), advancing age (p = 0.044), and use of absorbable nasal packing (p = 0.014). Health status (multidimensional QOL) was also predictive at 2 weeks (p = 0.001) and 3 months (p < 0.001) and was the only significant predictor of sinonasal QOL at 6 months (p < 0.001). A Kaplan-Meier analysis was performed to study time to resolution of nasal crusting, mucopurulence, and synechia as observed during nasal endoscopy after surgery. The mean time (± SEM) to absence of nasal crusting was 16.3 ± 2.1 weeks, mucopurulence was 6.2 ± 1.1 weeks, and synechia was 4.4 ± 0.5 weeks. Use of absorbable nasal packing was associated with more severe mucopurulence. Sinonasal QOL following endoscopic pituitary surgery reaches a nadir at 2 weeks and recovers by 3 months postoperatively. Use of absorbable packing and nasal splints, while used in a minority of patients, negatively correlates with early sinonasal QOL. Sinonasal QOL and overall health status are well correlated in the postoperative period, suggesting the important influence of sinonasal QOL on the patient experience.

Comparison of Sinonasal Quality of Life between Patients undergoing Microscopic and Endoscopic Transsphenoidal Surgery for Pituitary Lesions: A Prospective Cohort Study

Comparison of Sinonasal Quality of Life between Patients undergoing Microscopic and Endoscopic Transsphenoidal Surgery for Pituitary Lesions: A Prospective Cohort Study

Late Onset of CSF Rhinorrhea in a Postoperative Transsphenoidal Surgery Patient Following Robotic-Assisted Abdominal Hysterectomy.

Cerebrospinal fluid (CSF) leak is the most commonly encountered perioperative complication in transsphenoidal surgery for pituitary lesions. Direct closure with a combination of autologous fat, local bone, and/or synthetic grafts remains the standard of care for leaks encountered at the time of surgery as well as postoperatively. The development of the vascularized nasoseptal flap as a closure technique has increased the surgeon’s capacity to correct even larger openings in the dura of the sella as well as widely exposed anterior skull base defects. Yet these advances in the technical nuances for management of post-transsphenoidal CSF leak are useless without the ability to recognize a CSF leak by physical examination, clinical history, biochemical testing, or radiographic assessment. Here, we report a case of a patient who developed a CSF leak 28 years after transsphenoidal surgery, precipitated by a robotic-assisted hysterectomy during which increased intra-abdominal pressure and steep Trendelenberg positioning were both factors. Given the remote nature of the patient’s transsphenoidal surgery and relative paucity of data regarding such a complication, the condition went unrecognized for several months. We review the available literature regarding risk and pathophysiology of CSF leak following abdominal surgery and propose the need for increased vigilance in identification of such occurrences with the increasing acceptance and popularity of minimally invasive abdominal and pelvic surgeries as standards in the field.

Nasal symptoms following endoscopic transsphenoidal pituitary surgery: assessment using the General Nasal Patient Inventory

The endoscopic approach for pituitary tumors is a recent innovation and is said to reduce the nasal trauma associated with transnasal transsphenoidal surgery. The authors assessed the temporal changes in the rhinological symptoms following endoscopic transsphenoidal surgery for pituitary lesions, using the General Nasal Patient Inventory (GNPI). The GNPI was administered to 88 consecutive patients undergoing endoscopic transsphenoidal surgery at 3 time points (presurgery, 3-6 months postsurgery, and at final follow-up). The total GNPI score and the scores for the individual GNPI questions were calculated and differences between groups were assessed once before surgery, several months after surgery, and at final follow-up. Of a maximum possible score of 135, the mean GNPI score at 3-6 months postsurgery was only 12.9 ± 12 and was not significantly different from the preoperative score (10.4 ± 13) or final follow-up score (10.3 ± 10). Patients with functioning tumors had higher GNPI scores than those with nonfunctioning tumors for each of these time points (p < 0.05). Individually, a mild increase in symptom severity was seen for symptoms attributable to the nasal trauma of surgery, with partial recovery (nasal sores and bleeding) or complete recovery (nasal blockage, painful sinuses, and unpleasant nasal smell) by final follow-up (p < 0.05). Progressive improvements in symptom severity were seen for symptoms more attributable to tumor mass preoperatively (for example, headaches and painkiller use [p < 0.05]). In total, by final follow-up 8 patients (9%) required further treatment or advice for ongoing nasal symptoms. Endoscopic transsphenoidal surgery is a well-tolerated minimally invasive procedure for pituitary fossa lesions. Overall patient-assessed nasal symptoms do not change, but some individual symptoms may show a mild worsening or overall improvement.

Complications after trans-sphenoidal surgery: our experience and a review of the literature

The incidence of surgical complications after trans-sphenoidal surgery for pituitary lesions is low. The influence of size of thelesion and its pathology on the incidence of different types of complications and the remission rate of functioning adenomasare addressed in this retrospective study. Between 1996 and 2001, 126 trans-sphenoidal operations were performed on 108patients with pituitary pathologies. Diabetes insipidus (DI) was the commonest (23%) and the incidence was higher withmicroadenomas and in those with Cushing's disease (p < 0.05). Other important complications were: postoperativehypopituitarism 22%, CSF leak 13%, meningitis 5.5%, pneumocephalus 2.4%, visual deterioration 1.5%, haematoma 0.8%and 30-day mortality rate of 0.8%. Other complications encountered were subdural haematoma, epistaxis, SIADH, sphenoidabscess, deep vein thrombosis, thalamic infarct and hydrocephalus. No vascular injuries were encountered. The overallremission rate for acromegaly and Cushing's disease (22 patients each) was 77 and 81%, respectively. The remission rate was100% for microadenomas, 89% for both acromegaly and Cushing's disease. More aggressiveness towards complete tumourremoval increases the biochemical cure rate of functioning adenomas and on the other hand results in higher incidence of CSFleak and hypopituitarism.