Analysis of 137 Patients Who Underwent Endoscopic Transsphenoidal Pituitary Adenoma Resection Under High-Field Intraoperative Magnetic Resonance Imaging Navigation

3 Tesla intra-operative MRI as an adjunct to endoscopic pituitary surgery: an early assessment of clinical utility

BACKGROUND

Extent of resection is a major determinant of outcomes following pituitary surgery. Intra-operative magnetic resonance imaging (iMRI), provides an immediate assessment of the extent of resection, allowing further tumour resection during the same procedure. However, such systems are expensive and significantly increase operative time, prompting some authors to question the additional benefit conferred by iMRI when combined with endoscopy. Our aim was to assess the impact of combining 3 T iMRI with endoscopy in patients with pituitary tumours.

METHODS

We retrospectively reviewed a prospectively maintained database to identify patients who underwent iMRI guided endoscopic resection of pituitary tumours between May 2017 and November 2018 (iMRI cohort). This cohort was compared with a pre-iMRI cohort of patients who underwent endoscopic resection of pituitary adenomas. Operative time, extent of resection, control of endocrine disease and post-operative complications were recorded and analysed.

RESULTS

Thirty-seven patients were included in each cohort. iMRI facilitated additional tumour resection in 6/37 (16%) of cases. In 4/37 cases (11%), iMRI prompted a return to theatre but no further tumour could be identified. The overall GTR rate, following iMRI was 24/37 (65%) as compared to 21/37 (57%) in the pre-iMRI cohort. Cure of endocrine disease associated with hormonally active tumours was achieved in 9/11 (82%) of cases in the iMRI cohort. The mean operative time in the iMRI cohort was 327 minutes (five hours 27 minutes).

CONCLUSIONS

3 T iMRI provides immediate identification of residual tumour following endoscopic pituitary surgery. This allows for resection of surgically accessible residual disease during the same procedure and is likely to reduce the requirement for later re-intervention. However, the use of iMRI in this setting is associated with significant resource allocation issues which must be considered prior to the widespread adoption of this technique.

Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 1, general recommendations

Tumours of the anterior part of the pituitary gland represent just 1% of all childhood (aged <15 years) intracranial neoplasms, yet they can confer high morbidity and little evidence and guidance is in place for their management. Between 2014 and 2022, a multidisciplinary expert group systematically developed the first comprehensive clinical practice consensus guideline for children and young people under the age 19 years (hereafter referred to as CYP) presenting with a suspected pituitary adenoma to inform specialist care and improve health outcomes. Through robust literature searches and a Delphi consensus exercise with an international Delphi consensus panel of experts, the available scientific evidence and expert opinions were consolidated into 74 recommendations. Part 1 of this consensus guideline includes 17 pragmatic management recommendations related to clinical care, neuroimaging, visual assessment, histopathology, genetics, pituitary surgery and radiotherapy. While in many aspects the care for CYP is similar to that of adults, key differences exist, particularly in aetiology and presentation. CYP with suspected pituitary adenomas require careful clinical examination, appropriate hormonal work-up, dedicated pituitary imaging and visual assessment. Consideration should be given to the potential for syndromic disease and genetic assessment. Multidisciplinary discussion at both the local and national levels can be key for management. Surgery should be performed in specialist centres. The collection of outcome data on novel modalities of medical treatment, surgical intervention and radiotherapy is essential for optimal future treatment.

Learning Curve for Endoscopic Transsphenoidal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic transsphenoidal surgery (ETSS) is emerging as an effective, minimally invasive surgery technique for brain tumors of the pituitary fossa. Using a surgical endoscope, surgeons can obtain a broader, nearer, and more apparent visual field with minimal keyhole entrance. However, ETSS may require a steep learning curve to achieve technical competence and relevant outcomes. Moreover, there is no consensus on the learning process of ETSS. We aimed to review and determine the technical proficiency points of ETSS and discuss how to accelerate the learning curve.

METHODS

Core databases, including PubMed, Embase, and the Cochrane Library, were systematically searched for learning curve studies that demonstrated the clinical outcomes and learning status of ETSS for pituitary adenomas using numerical data. Quality assessments of the included articles were performed using the Newcastle-Ottawa scale. The cutoff points were evaluated based on various outcome measures.

RESULTS

Eleven full-text articles, representing 2780 cases, were selected from 317 screened studies. The outcome measures were operative time, tumor removal, endocrinological results, visual field, and surgical complications. The plateaus or cutoff points in the learning curve varied with a mean of 103 ± 139.43 (range, 9-500) cases.

CONCLUSIONS

ETSS is an efficient and minimally invasive alternative surgical option for pituitary tumors. Plateau points may differ according to outcome measures, patient selection, training status, and surgical conditions. Therefore, great care should be taken when interpreting the learning curve. A systematic training program is essential to improve the learning process of endoscopic neurosurgical procedures.

Classification of Pituitary Adenomas Invading the Cavernous Sinus Assisted by Three-Dimensional Multimodal Imaging and Its Clinical Application

Introduction  To help diagnose and evaluate the prognosis of pituitary adenoma with cavernous sinus (CS) invasion and guide endonasal endoscopic surgery (EES) assisted by intraoperative navigation (ION) with three-dimensional multimodal imaging (3D-MMI). We propose a classification of CS invasion based on 3D-MMI. Methods  We picked some appropriate cases and reconstructed the 3D-MMI and then classified them into 3 grades according to the stereo relationship among ICA, tumor and CS in 3D-MMI. Then, we applied different strategies according to their grade to remove pituitary adenomas that invaded the CS. Results  All 38 patients were divided into 3 grades. Tumors compressing the ICA and CS without CS invasion were divided into grade 1. Tumors encasing the ICA and invading the superior-posterior compartment and/or anterior-inferior compartment but without distinct separation of the ICA and CS lateral wall were deemed as grade 2. Tumors encasing the ICA and filling the lateral compartment of the CS that dissociated the lateral wall from the ICA were deemed as grade 3. The 3D-MMI enabled adequate spatial visualization of the ICA, CS and tumors. All patients were operated on under the guidance of ION with 3D-MMI. Conclusion  Classification based on 3D-MMI can better demonstrate the relationships among tumor, ICA and CS in a stereo and multi-angle view, which will have significance in guiding the surgical strategy.

Impact of intraoperative magnetic resonance imaging on gross total resection, extent of resection, and residual tumor volume in pituitary surgery: systematic review and meta-analysis

BACKGROUND

Residual tumor tissue after pituitary adenoma surgery, is linked with additional morbidity and mortality. Intraoperative magnetic resonance imaging (ioMRI) could improve resection. We aim to assess the improvement in gross total resection (GTR), extent of resection (EOR), and residual tumor volume (RV) achieved using ioMRI.

METHODS

A systematic review was carried out on PubMed/MEDLINE to identify any studies reporting intra- and postoperative (1) GTR, (2) EOR, or (3) RV in patients who underwent resection of pituitary adenomas with ioMRI. Random effects meta-analysis of the rate of improvement after ioMRI for these three surgical outcomes was intended.

RESULTS

Among 34 included studies (2130 patients), the proportion of patients with conversion to GTR (∆GTR) after ioMRI was 0.19 (95% CI 0.15-0.23). Mean ∆EOR was + 9.07% after ioMRI. Mean ∆RV was 0.784 cm3. For endoscopically treated patients, ∆GTR was 0.17 (95% CI 0.09-0.25), while microscopic ∆GTR was 0.19 (95% CI 0.15-0.23). Low-field ioMRI studies demonstrated a ∆GTR of 0.19 (95% CI 0.11-0.28), while high-field and ultra-high-field ioMRI demonstrated a ∆GTR of 0.19 (95% CI 0.15-0.24) and 0.20 (95% CI 0.13-0.28), respectively.

CONCLUSIONS

Our meta-analysis demonstrates that around one fifth of patients undergoing pituitary adenoma resection convert from non-GTR to GTR after the use of ioMRI. EOR and RV can also be improved to a certain extent using ioMRI. Endoscopic versus microscopic technique or field strength does not appear to alter the impact of ioMRI. Statistical heterogeneity was high, indicating that the improvement in surgical results due to ioMRI varies considerably by center.

Differential independent impact of the intraoperative use of navigation and angled endoscopes on the surgical outcome of endonasal endoscopy for pituitary tumors: a prospective study

Despite widespread popularity of navigation and angled endoscopes in endonasal endoscopy, there are hardly few studies on their efficacy with the extent of resection or retreatment. This is probably the first study to assess the independent impact of these adjuncts among pituitary tumors. Patients with pituitary tumors undergoing endonasal endoscopy were prospectively studied for their demographics, clinico-radiological features, intraoperative use of navigation, and angled endoscopes, in relation to gross total resection (GTR), near total resection (NTR), endocrine remission, and retreatment. Pertinent statistical analyses were performed. Among a total of 139 patients, navigation and angled endoscopes could be used in 54 and 48 patients, respectively, depending upon their availability rather than chosen as per the case. There was no significant difference in baseline characteristics in relation to their use. The surgeon's perception of immediate benefit was noted among 51.9% while using navigation. The use of angled endoscopes towards the end of resection could help with additional tumor removal in 62.5% of patients. Overall, the use of navigation resulted in a significantly higher GTR (80.8% vs. 59.7%, OR 2.83, p = 0.01), a higher GTR/NTR (86.5% vs. 70.8%, OR 2.65, p = 0.04), and a lower retreatment rate (7.7% vs. 20.8%, OR 3.15, p = 0.05) than the others. In functioning tumors with cavernous sinus invasion, navigation had significantly increased remission rates (69.2% vs. 0%, p = 0.03). The use of angled endoscopes yielded a significantly higher GTR/NTR (91.7% vs. 70.6%, p = 0.04) and a lower retreatment rate (0% vs. 15.7%, p = 0.05) among only non-functioning adenomas. In multivariate analyses, the use of neuronavigation had a significant association with both GTR and retreatment rates (p values 0.005 and 0.02 respectively), independent of other confounding factors. The elective intraoperative use of navigation has a significant independent impact on the extent of resection and retreatment overall. While navigation results in better remission rates among functioning tumors with cavernous sinus invasion, angled endoscopy has a significant association with surgical outcomes in non-functioning tumors.

Sources of residuals after endoscopic transsphenoidal surgery for large and giant pituitary adenomas

BACKGROUND

Giant and large pituitary adenomas (PA) constitute a specific subset of PAs, with gross total resection (GTR) rates frequently not exceeding 50%. Both an anatomical inaccessibility and an inadequate tumor visualization are thought to play a role. This study analyzes risk factors for postoperative residuals after endoscopic transsphenoidal pituitary surgery for large and giant pituitary adenomas.

METHODS

A retrospective analysis of patients with giant and large PA operated between 2015 and 2018 was performed.

RESULTS

Forty patients (13 females, 27 males) were included in the analysis (30 large and 10 giant PAs). The mean MRI follow-up time was 5.9 ± 6.54 months. Overall, GTR was achieved in 29 patients (72.5%), subtotal resection in 9 (22.5%), and the inconclusive result was in 2 (5%). Unexpected residuals represented 7 (77.7%) of all 9 residual tumors. The most frequent intraoperative factor associated with unexpected residual tumors was improper identification of residual tumor due to obstruction of view in 2 (28.5%) cases and inability to distinguish normal tissue from tumor in the other two (28.5%). Sub-analysis based on tumor size revealed that with large PAs, GTR was achieved in 25 (83.3%), STR in 4 (13.3%), and inconclusive in 1 (3.3%) patient. In patients with giant PAs, GTR was achieved in 4 (40%), STR in 5 (50%), and inconclusive in 1 (10%). Analysis of preoperative factors showed a significant association of residual tumors with larger suprasellar AP distance (p = 0.041), retrosellar extension (p = 0.007), and higher Zurich Score (p = 0.029).

CONCLUSION

Large and giant PAs are challenging lesions with high subtotal resection rates. Suprasellar AP distance, retrosellar extension, and higher Zurich Score seem to be significant predictors of degree of resection in these tumors. Improving the intraoperative ability to distinguish tumor from a normal tissue might further decrease the number of unexpected residuals.

Radiographic and clinical outcomes using intraoperative magnetic resonance imaging for transsphenoidal resection of pituitary adenomas

OBJECTIVE

The utility and safety of intraoperative MRI (iMRI) for resection of pituitary adenomas is not clearly established in the context of advances in endoscopic approaches. The goal in this study was to evaluate the safety and efficacy of iMRI for pituitary adenoma resection, with endoscopic transsphenoidal (ETS) versus microscopic transsphenoidal (MTS) approaches.

METHODS

Radiographic and clinical outcomes of all pituitary adenomas resected using iMRI between 2008 and 2017 at a single institution were retrospectively evaluated.

RESULTS

Of 212 tumors treated, 131 (62%) underwent further resection based on iMRI findings, resulting in a significant increase in gross-total resection on postoperative MRI compared with iMRI (p = 0.0001) in both ETS and MTS groups. iMRI increased rates of gross-total resection for cavernous sinus invasion Knosp grades 1 and 2, but not in Knosp ≥ 3 across treatment groups (p < 0.0001). The extent of resection on postoperative MRI was significantly correlated with increased progression-free survival (p < 0.0001). Initial hormone remission off medical therapy was achieved in 64%, with a significantly higher rate of remission in tumors resected via the ETS approach (81%) compared with the MTS approach (55%) (p = 0.02). The rate of persistent new hormone deficit was low at 8%, including a 2.8% rate of permanent diabetes insipidus, and 45% of patients had improvement in preoperative hormone deficit following surgery. Serious postoperative complications including CSF leaks requiring reoperation were rare at 1%, with no postoperative infections.

CONCLUSIONS

These results suggest that iMRI is a safe and effective method of increasing the extent of resection for pituitary adenomas while preserving hormone function. When paired with the endoscope, iMRI may offer the ability to tailor more aggressive removal of tumors while optimizing pituitary function, resulting in high rates of secretory hormone remission. Secretory tumors and adenomas with Knosp grade < 3 cavernous sinus invasion may benefit most from the use of iMRI.

Application of intra-operative magnetic resonance imaging for intracranial epidermoid cysts

The effectiveness and safety of intraoperative magnetic resonance imaging (iMRI) are evident from many reports over the past decade. However, these reports have mainly concerned surgeries for glioma and other intra-axial tumours, and applications of this approach for extra-axial tumours are poorly documented. We retrospectively examined three cases in which iMRI was used to assist in the removal of epidermoid cysts. T2-weighted images and diffusion-weighted images were acquired during the surgeries. The value to surgeons of images generated by iMRI, the length of interruption of surgery, and the safety of the patients were assessed. In this study, the images obtained through iMRI provided were clear representations of remnant tumours, even with a low-field system (0.4 Tesla). These images generated enough information to help surgeons decide whether to use an assistance device, such as an endoscope, to remove remnant tumours and whether further retraction of the brain was safe for patients and useful in tumour removal. Intraoperative MRI has long been thought unnecessary for surgery for tumours that are well demarcated and clearly visible under a surgical microscope; in this study, however, intraoperative MRI proved to be useful and safe for patients undergoing epidermoid cyst resection.

Challenges, Learning Curve, and Safety of Endoscopic Endonasal Surgery of Sellar-Suprasellar Lesions in a Community Hospital

BACKGROUND AND OBJECTIVE

Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting.

METHODS

We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018.

RESULTS

There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients.

CONCLUSIONS

EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.

Intra-operative MRI vs endoscopy in achieving gross total resection of pituitary adenomas: a systematic review

BACKGROUND

Intraoperative magnetic resonance imaging (iMRI) is a technology that may improve rates of gross total resection (GTR) for pituitary adenomas. The endoscope is another less expensive technology, which also may maximize resection rates. A direct comparison of these approaches and their additive benefit has never been performed.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard. PubMed and Embase databases were searched for studies that examined GTR for pituitary adenoma resection with either endoscopic transsphenoidal surgery (eTSS), microscopic transsphenoidal surgery with iMRI (mTSS + iMRI), or endoscopic transsphenoidal surgery with iMRI (eTSS + iMRI).

RESULTS

Eighty-five studies that reported GTR rates in 7124 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS had a pooled proportion of GTR of 68.9% (95% CI 64.7-73.0%) which was similar to that of mTSS + iMRI (GTR 68.3%; 95% CI = 59.4-76.5%) and eTSS + iMRI (GTR 70.7%; 95% CI = 56.9-89.6%). For the subgroup of pituitary macroadenomas, pooled proportions for GTR were similar between eTSS and mTSS + iMRI (eTSS: GTR 59.4%; 95% CI = 49.6-68.7% vs mTSS + iMRI: GTR 68.8%; 95% CI = 57.3-79.3%), and higher for eTSS + iMRI (81.1%; 95% CI = 75.5-86.2%). The post-operative CSF leak proportion for eTSS (4.7%; 95% CI = 3.6-5.9%) was similar to that for eTSS + iMRI (3.7%; 95% CI = 1.6-6.5%) and mTSS + iMRI (4.6%; 95% CI = 2.0-8.3%). No direct statistical comparisons could be performed.

CONCLUSION

Final GTR proportions are similar whether the surgeon uses a microscope supplemented with iMRI or endoscope with or without iMRI. The benefit of the two technologies may be complementary for macroadenomas. These findings are important to consider when comparing the efficacy of different technical strategies in the management of pituitary adenomas.

High-Field Intraoperative Magnetic Resonance Imaging Increases Extent of Resection and Progression-Free Survival for Nonfunctioning Pituitary Adenomas

BACKGROUND

The effect of intraoperative magnetic resonance imaging (iMRI) on tumor control during endoscopic transsphenoidal surgery (TSS) for nonfunctioning pituitary adenomas (NFPAs) has not yet been completely characterized. The present study assessed the effect of the iMRI findings on gross total resection (GTR) and progression-free survival at a mean follow-up of 62 ± 9.4 months.

METHODS

Retrospective analyses were performed on the data from 133 consecutive patients with NFPA who had undergone endoscopic TSS with iMRI using a 1.5T scanner.

RESULTS

Compared with the first and final iMRI scans, the GTR rate increased from 42.9% to 63.9%. Multivariate logistic regression analysis revealed that a lower GTR rate was associated with a higher Knosp score (odds ratio [OR], 3.612; 95% confidence interval [CI], 1.568-8.321; P = 0.003), an increased tumor volume (OR, 0.926; 95% CI, 0.866-0.991; P = 0.025), and a history of surgery (OR, 0.376; 95% CI, 0.155-0.917; P = 0.031). During follow-up, 8 tumors (9.4%) recurred, and 29 remnants (60.4%) regenerated. The recurrence and regeneration rates were 0.019 and 0.121 patient/year, respectively. Kaplan-Meier analysis revealed that the tumor recurrence rates were lower for patients who had undergone GTR (P < 0.01) compared with those who had not. Univariate Cox regression analysis suggested that the presence of tumor remnants (hazard ratio, 1.546; 95% CI, 1.071-2.232; P = 0.02) was the influencing factor associated with tumor progression.

CONCLUSIONS

High-field iMRI can increase the GTR rate in endoscopic TSS for NPFAs. The increased GTR rate was associated with longer progression-free survival. Cavernous sinus invasion, tumor size, and surgical history were important predictors of GTR in patients with NFPA.

The optimal surgical techniques for pituitary tumors

In this paper, the currently used and well evaluated techniques for the surgery of pituitary tumors will be reviewed. Since the first surgical approaches to pituitary tumors more than 100 years have elapsed. Various surgical techniques have been developed, refined and standardized. Most of these tumors are to date treated via transsphenoidal approaches. Many pituitary adenomas, particularly, smaller, enclosed ones, can be completely excised and a selective adenomectomy is usually attempted. It leads to remission of hormonal oversecretion and also to recovery of pituitary function in many patients. The resection of pseudocapsule around the adenoma seems to improve the operative results further. Transcranial approaches, employing craniotomies, are still needed in some patients with pituitary adenomas and in many of those harbouring craniopharyngiomas. The operative techniques will be described and briefly commented. Moreover, the application and usefulness of several technical developments will be reviewed, such as the use of the endoscope, magnetic resonance imaging, fluorenscent dyes and neuronavigation. The use of the intraoperative Doppler probe, ultrasound and the value of intraoperative hormonal measurements will be briefly discussed. There is sufficient evidence that the best and optimal outcome in terms of tumor resection and correction of hormonal oversecretion as well as the lowest rate of complications are obtained in centers of excellence with sufficiently experienced, specialized surgeons and a high patient load.

Technological and Ideological Innovations in Endoscopic Skull Base Surgery

BACKGROUND

Endoscopic skull base surgery has evolved over the last several decades due to technological advances and operative techniques. Several innovations that are not yet mainstream may have significant impact on the future of endoscopic skull base surgery.

METHODS

Current literature pertaining to innovations in endoscopic skull base surgery was retrieved using PubMed, Embase, Web of Science, and Google Scholar.

RESULTS

Several recent innovations may play an influential role in the advancement of endoscopic skull base surgery, including fluorescent dyes such as indocyanine green fluorescence, fluorescein, and 5-aminolevulinic acid, 3-dimensional endoscopes, robotic surgery, and intraoperative magnetic resonance imaging.

CONCLUSIONS

Several technologies are under current investigation with the hope to improve future outcomes in endoscopic skull base surgery. Additional research and evolution are necessary and will require intense scrutiny before becoming standard of care.

[Differential diagnosis and treatment of pituitary adenomas]

Pituitary adenomas are among the most common primary brain tumors. These tumors can produce all hormones of the anterior pituitary and thus cause endocrine diseases. Compression of the pituitary gland, the surrounding cranial nerves, or brain structures can lead to hypopituitarism, cranial nerve deficits, or diverse neurological symptoms. Visual impairment, typically with bitemporal hemianopsia, is the most common cardinal symptom. The diagnostic workup requires broad interdisciplinary cooperation. With the exception of prolactinoma, the treatment of choice for symptomatic pituitary adenoma is transnasal transsphenoidal resection. For prolactinoma, dopamine agonistic therapy is the primary treatment. Adequate hormone replacement therapy is essential in cases of hypopituitarism. Long-term follow-up is a vital part of the treatment concept.

Advanced Endoscopic Navigation: Surgical Big Data, Methodology, and Applications

Interventional endoscopy (e.g., bronchoscopy, colonoscopy, laparoscopy, cystoscopy) is a widely performed procedure that involves either diagnosis of suspicious lesions or guidance for minimally invasive surgery in a variety of organs within the body cavity. Endoscopy may also be used to guide the introduction of certain items (e.g., stents) into the body. Endoscopic navigation systems seek to integrate big data with multimodal information (e.g., computed tomography, magnetic resonance images, endoscopic video sequences, ultrasound images, external trackers) relative to the patient's anatomy, control the movement of medical endoscopes and surgical tools, and guide the surgeon's actions during endoscopic interventions. Nevertheless, it remains challenging to realize the next generation of context-aware navigated endoscopy. This review presents a broad survey of various aspects of endoscopic navigation, particularly with respect to the development of endoscopic navigation techniques. First, we investigate big data with multimodal information involved in endoscopic navigation. Next, we focus on numerous methodologies used for endoscopic navigation. We then review different endoscopic procedures in clinical applications. Finally, we discuss novel techniques and promising directions for the development of endoscopic navigation.

History, Current Situation, and Future Development of Endoscopic Neurosurgery in China

OBJECTIVE

During the past few decades, Chinese endoscopic neurosurgery has rapidly developed in synchrony with the rest of the world. The aim of this article is to review the development of Chinese endoscopic neurosurgery, including its birth, growth, current situation, and prospects.

METHODS

The history of Chinese endoscopic neurosurgery development can be divided into 3 stages: cognition and initial stage (1964-1995), exploration and maturity stage (1995-2006), and rapid development and promotion stage (2006-present).

RESULTS

In the first stage, we mainly began to become aware of endoscopic neurosurgery from the translation and review of literature. In the mid to late 1990s, Chinese neurosurgery pioneers began using neuroendoscopic techniques. In the following decade, many leading neurosurgeons made persistent efforts to push the development of Chinese endoscopic neurosurgery forward, focusing on advocating for and promoting and popularizing neuroendoscopic technology. In the rapid development and promotion stage, many representative national and regional neurosurgical centers became skilled and efficient in the application of neuroendoscopic technology and became new advocates of the technology. The number of cases, level of technology, and treatment effectiveness are gradually nearing international standards. However, future development requires promotion of balanced development to decrease regional disparities, further strengthen international exchanges, follow the latest developments, and constantly innovate for continuous improvement.

CONCLUSIONS

Following the dramatic efforts of several pioneers, development of Chinese endoscopic neurosurgery has been considerable, and it has become an important component of neurosurgery worldwide.