Retrosigmoid versus translabyrinthine approach to acoustic neuroma resection: A comparative cost-effectiveness analysis

Feasibility Analysis and Surgical Details of Vestibular Schwannoma Resection via Retrolabyrinthine Approach With Preservation of Endolymphatic Sac

Objectives: To study the feasibility of reserving the endolymphatic sac in the cerebellopontine angle (CPA) and the fundus of the internal auditory canal (IAC) by the retrolabyrinthine approach. Design: Single-center retrospective study. Methods: Through 3-dimensional preoperative computed tomography reconstruction, vestibular schwannoma (VS) resection was performed using a retrolabyrinthine approach with preservation of the endolymphatic sac in selected patients, and hearing and facial nerve functions were followed to assess the feasibility of this operation and the effectiveness of function preservation. Results: VS was completely removed in all cases and the postoperative detectable hearing retention rate (AAO-HNS hearing rating grade A, B, and C) was 80% (4/5). Postoperative facial nerve function was well preserved (HB grade I), no leakage of cerebrospinal fluid or other cranial complications was observed in all patients, and no recurrence was observed during follow-up. Conclusions: With less trauma and a promising route for hearing preservation and facial nerve functions, the retrolabyrinthine approach is a potential choice for the treatment of VS located in the IAC-CPA.

Surgical management of spontaneous middle cranial fossa defects: a systematic review and meta-analysis of available reconstructive techniques and materials

Different materials and techniques have been proposed for surgical repair of spontaneous middle cranial fossa (MCF) defects. However, conclusive evidence supporting their selection and impact on clinical outcomes is lacking. The study aims to conduct a systematic review and meta-analysis on materials and techniques employed to repair MCF defects and evaluate complications and rates of recurrent cerebrospinal fluid (CSF) leaks. A PRISMA-guided systematic review and meta-analysis were performed using MESH terms and specific keywords including studies published before May 2022. Primary outcomes included recurrence of CSF leak and complication rates by type of reconstructive material and technique utilized. Meta-analyses of proportions were performed using random effects and confidence intervals for individual proportions were calculated using the Clopper-Pearson method. Twenty-nine studies were included (n = 471 cases). Materials employed for repair were categorized according to defect size: 65% of defects were of unknown size, 24% were small (< 1 cm), and 11% were large (≥ 1 cm). Rigid reconstruction (RR) was significantly favored over soft reconstruction (SR) for larger defects (94% of cases, p < 0.05). Complications and recurrent CSF leak rates of SR and RR techniques were comparable for defects of all sizes (p > 0.05). Complication rates reported for these procedures are low regardless of technique and material. RR was universally preferred for larger defects and analysis of complication and recurrence rates did not reveal differences regardless of defect size. While RR was more frequently reported in smaller defects, SR was used by several centers, particularly for smaller MCF floor defects.

Functional Outcomes and Postoperative Cerebral Venous Sinus Thrombosis after Translabyrinthine Approach for Vestibular Schwannoma Resection: A Radiographic Demonstration of Anatomic Predictors

Introduction While regarded as an effective surgical approach to vestibular schwannoma (VS) resection, the translabyrinthine (TL) approach is not without complications. It has been postulated that postoperative cerebral venous sinus thrombosis (pCVST) may occur as a result of injury and manipulation during surgery. Our objective was to identify radiologic, surgical, and patient-specific risk factors that may be associated with pCVST.

Methods The Institutional Review Board (IRB) approval was obtained and the medical records of adult patients with VS who underwent TL craniectomy at University Hospitals Cleveland Medical Center between 2009 and 2019 were reviewed. Demographic data, radiographic measurements, and tumor characteristics were collected. Outcomes assessed included pCVST and the modified Rankin score (mRS).

Results Sixty-one patients ultimately met inclusion criteria for the study. Ten patients demonstrated radiographic evidence of thrombus. Patients who developed pCVST demonstrated shorter internal auditory canal (IAC) to sinus distance (mean: 22.5 vs. 25.0 mm, p = 0.044) and significantly smaller petrous angles (mean: 26.3 vs. 32.7 degrees, p = 0.0045). Patients with good mRS scores (<3) appeared also to have higher mean petrous angles (32.5 vs. 26.8, p = 0.016). Koos' grading and tumor size, in our study, were not associated with thrombosis.

Conclusion More acute petrous angle and shorter IAC to sinus distance are objective anatomic variables associated with pCVST in TL surgical approaches.

Reducing ICU Length of Stay: The Impact of a Multidisciplinary Perioperative Pathway in Vestibular Schwannoma

Objective This study was aimed to evaluate the impact of a multidisciplinary perioperative pathway on length of stay (LOS) and postoperative outcomes after vestibular schwannoma surgery.

Setting This study was conducted in a tertiary skull base center.

Main Outcome Measures The impact of the pathway on intensive care unit (ICU) LOS was evaluated as the primary outcome measure of the study. Overall resource LOS, postoperative complications, and readmission rates were also evaluated as secondary outcome measures.

Methods Present study is a retrospective review.

Results A universally adopted perioperative pathway was developed to include standardization of preoperative education and expectations, intraoperative anesthetic delivery, postoperative nursing education, postoperative rehabilitation, and utilization of stepdown and surgical floor units after ICU stay. Outcomes were measured for 95 consecutive adult patients who underwent surgical resection for vestibular schwannoma (40 cases before implementation of the perioperative pathway and 55 cases after implementation). There were no significant differences in the two groups with regard to tumor size, operative time, or medical comorbidities. The mean ICU LOS decreased from 2.1 in the preimplementation group to 1.6 days in the postimplementation group (p = 0.02). There were no significant differences in overall resource LOS postoperative complications or readmission rates between groups.

Conclusion Multidisciplinary, perioperative neurotologic pathways can be effective in lowering ICU LOS in patients undergoing vestibular schwannoma surgery without compromising quality of care. Further research is needed to continue to sustain and continuously improve these and other measures, while continuing to provide high-quality care to this patient population.

Tumor-Related and Patient-Related Variables Affecting Length of Hospital Stay Following Vestibular Schwannoma Microsurgery

OBJECTIVE

Review a single institution's vestibular schwannoma (VS) microsurgery experience to determine (1) correlations between demographics, comorbidities, and/or surgical approach on hospital length of stay (LOS) and discharge disposition and (2) trends in surgical approach over time.

METHODS

Retrospective case series from a multidisciplinary skull base program at a tertiary care, academic hospital. All adult (>18 years) patients undergoing primary microsurgery for VS between 2008 and 2018 were included.

RESULTS

A total of 147 subjects were identified. Surgical approach was split between middle fossa (MF) (16%), retrosigmoid (RS) (35%), and translabyrinthine (TL) (49%) craniotomies. For the 8% of patients had other than routine (OTR) discharge. Mean LOS was significantly longer for patients undergoing RS than either MF or TL. Brainstem compression by the tumor was associated with longer LOS as were diagnoses of chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD). For all discharges, the 40 to 50- and 50 to 60-year-old subgroups had significantly shorter LOS than the 70-years-and-older patients. For the 92% of patients routinely discharged, there was a significantly shorter LOS in the 40 to 50-year-olds compared to the 70-years-and-older patients. There was a significant shift in surgical approach from RS to TL over the study period.

CONCLUSION

Over 90% of VS microsurgery patients were routinely discharged with a median hospital LOS of 3.2 days, both of which are consistent with published data. There is an inverse relationship between age and LOS with patients older than 70 years having significantly longer LOS. Brainstem compression, COPD, PVD, and the RS approach negatively affect LOS.

LEVEL OF EVIDENCE

4.

Sigmoid Sinus Patency following Vestibular Schwannoma Resection via Retrosigmoid versus Translabyrinthine Approach

Introduction The treatment options for acoustic neuromas are observation with serial imaging, stereotactic radiation, or surgical resection. The most common surgical approaches are the translabyrinthine (TL), the retrosigmoid (RS), and the middle cranial fossa. During the TL approach the sigmoid sinus is decompressed with bipolar cautery to allow greater medial exposure. It is unknown if this causes any long-term narrowing or thrombus of the sigmoid sinus.

Methods We performed a retrospective review of patients who underwent acoustic neuroma resection to determine if patients undergoing a TL approach for acoustic neuroma resection develop radiographic evidence of sigmoid sinus stenosis or thrombosis compared with patients undergoing a RS approach.

Results A total of 128 patients were included in this study, 56 patients underwent a TL approach and 72 patients underwent a RS approach. We compared the preoperative and postoperative diameter of the ipsilateral and contralateral sigmoid sinus at proximal, midpoint, and distal locations on magnetic resonance imaging examinations. There was no significant difference between the preoperative and postoperative diameter of the ipsilateral or contralateral sigmoid sinus based on surgical approach.

Conclusion Decompression of the sigmoid sinus during the TL approach does not have a significant postoperative effect on the dural venous sinus patency.

Comparing costs of microsurgical resection and stereotactic radiosurgery for vestibular schwannoma

OBJECTIVE

Given rising scrutiny of healthcare expenditures, understanding intervention costs is increasingly important. This study aimed to compare and characterize costs for vestibular schwannoma (VS) management with microsurgery and radiosurgery to inform practice decisions and appraise cost reduction strategies.

METHODS

In conjunction with medical records, internal hospital financial data were used to evaluate costs. Total cost was divided into index costs (costs from arrival through discharge for initial intervention) and follow-up costs (through 36 months) for 317 patients with unilateral VSs undergoing initial management between June 2011 and December 2015. A retrospective matched cohort based on tumor size with 176 patients (88 undergoing each intervention) was created to objectively compare costs between microsurgery and radiosurgery. The full sample of 203 patients treated with resection and 114 patients who underwent radiosurgery was used to evaluate a broad range of outcomes and identify cost contributors within each intervention group.

RESULTS

Within the matched cohort, average index costs were significantly higher for microsurgery (100% by definition, because costs are presented as a percentage of the average index cost for the matched microsurgery group; 95% CI 93-107) compared to radiosurgery (38%, 95% CI 38-39). Microsurgery had higher average follow-up costs (1.6% per month, 95% CI 0.8%-2.4%) compared to radiosurgery (0.5% per month, 95% CI 0.4%-0.7%), largely due to costs incurred in the initial months after resection. A major contributor to total cost and cost variability for both resection and radiosurgery was the need for additional interventions in the follow-up period, which were necessary due to complications or persistent functional deficits. Although tumor size was not associated with increased total costs for radiosurgery, linear regression analysis demonstrated that, for patients who underwent microsurgery, each centimeter increase in tumor maximum diameter resulted in an estimated increase in total cost of 50.2% of the average index cost of microsurgery (95% CI 34.6%-65.7%) (p < 0.001, R2 = 0.17). There were no cost differences associated with the proportion of inpatient days in the ICU or with specific surgical approach for patients who underwent resection.

CONCLUSIONS

This study is the largest assessment to date based on internal cost data comparing VS management with microsurgery and radiosurgery. Both index and follow-up costs are significantly higher when tumors were managed with resection compared to radiosurgery. Larger tumors were associated with increased resection costs, highlighting the incremental costs associated with observation as the initial management.

Is There a Difference in Hospital Stay between Patients undergoing Translabyrinthine or Retrosigmoid Surgery for Vestibular Schwannoma Stratified by Tumor Size?

Objective  To date, no European study has compared approach-specific outcome data in vestibular schwannoma (VS) surgery stratified by tumor size. We analyzed hospital length of stay (LOS), intensive therapy/high-dependency unit (ITU/HDU) LOS, and complications in patients undergoing VS surgery via the translabyrinthine (TL) versus retrosigmoid (RS) approaches, stratifying for tumor size. Design  Prospective database undergoing retrospective review. Setting  Tertiary center. Participants  A total of 117 patients with VS undergoing TL ( n  = 71) or RS ( n  = 46) surgical resection from 2011 to 2016 were analyzed. Data including age, gender, surgical approach, tumor size, hospital, and ITU/HDU LOS and postoperative complications were evaluated. Intervention(s)  Therapeutic-VS surgery via either TL or RS approach. Main Outcome Measure(s)  LOS (hospital/intensive care unit). Results  Hospital LOS was significantly greater in patients undergoing the RS approach versus TL approach in VS between 31 and 40 mm (11 versus 7 days, p  < 0.0006). The mean ITU/HDU LOS was greater in the RS group compared with the TL group (4.6 versus 1, p  > 0.05). Reported complications were higher in the RS group ( n  = 40 versus 22). A post hoc analysis of the 31 to 40 mm group revealed no statistically significant difference in the American Society of Anesthesiologists grade or preoperative performance status. Conclusions  In our practice, in VS sized 31 to 40 mm patients stay 4 days longer post RS compared with TL surgery. This translates to £1600 extra per patient in the UK. Our data may inform decision-making during the skull base multidisciplinary team and the consent process to help decide the ideal operative approach for the patient.