Endoscopic transsphenoidal tumor surgery

Value of anatomical landmarks in single-nostril endonasal transnasal-sphenoidal surgery

The sphenoid sinus occupies a central location in transsphenoidal surgery (TSS). It is important to identify relevant anatomical landmarks to enter the sphenoid sinus and sellar region properly. The aim of this study was to identify anatomical landmarks and their value in single-nostril endonasal TSS. A retrospective study was performed to review 148 cases of single-nostril endonasal TSS for pituitary lesions. The structure of the nasal cavities and sphenoid sinus, the position of apertures of the sphenoid sinus and relevant arteries and the morphological characteristics of the anterior wall of the sphenoid sinus and sellar floor were observed and recorded. The important anatomical landmarks included the mucosal aperture of the sphenoid sinus, a blunt longitudinal prominence on the posterior nasal septum, the osseocartilaginous junction of the nasal septum, the 'bow sign' of the anterior wall of the sphenoid sinus, the osseous aperture and its relationship with the nutrient arteries, the bulge of the sellar floor and the carotid protuberance. These landmarks outlined a clear route to the sella turcica with an optimal view and lesser tissue damage. Although morphological variation may exist, the position of these landmarks was generally consistent. Locating the sphenoid sinus aperture is the gold standard to direct the surgical route of TSS. The 'bow sign' and the sellar bulge are critical landmarks for accurate entry into the sphenoid sinus and sella fossa, respectively.

Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal

Object

Because of their size and lateral extension, total removal of nonfunctioning pituitary adenomas (NFPAs) remains a challenge and postoperative tumor remnants are frequent. Endoscopy has improved the surgeon's view; however, its superiority in terms of surgical outcome remains undetermined. The authors' aim in this study was to compare the clinical results and morbidity between microscopic and endoscopic techniques in 164 patients with NFPAs.

Methods

Tumoral (3D MR imaging), endocrinological, and ophthalmological results and morbidity were compared between 2 groups of 82 patients with newly diagnosed NFPAs surgically treated via either a sublabial microscopic approach (Group B) or a fully endonasal endoscopic technique (Group A).

Results

The groups showed no difference in terms of clinical features, tumor size, or cavernous sinus invasion (p > 0.05). One year postoperatively, the quality of resection was significantly improved in Group A (gross-total removal [GTR]: 74% vs 50% in Group B, p = 0.002) with greater control of lateral extension (Knosp Grade 2: GTR 88.2% vs 47.8% in Group B, p = 0.02; Knosp Grade 3: 67.9% vs 16.7% in Group B, p < 0.001) and suprasellar extension (tumor height 20–30 mm: GTR 76% vs 53% in Group B, p = 0.01). Endocrinological outcome in patients with a partial deficiency in anterior pituitary function preoperatively was significantly better in Group A (improvement 56% vs 25% in Group B, stabilization 22% vs 46%, and aggravation 22% vs 29%; p = 0.01). Among the ophthalmologically symptomatic patients, 100% from Group A improved compared with 93% in Group B (p = 0.35). Lastly, no significant difference was found regarding morbidity. These data were supported by the literature in which the GTR rate is consistently higher for endoscopy compared with microscopy.

Conclusions

In this large series of patients with NFPAs, endoscopy improved the quality of resection and endocrinological outcome. Larger studies focusing on the impact of these promising results on the long-term recurrence of NFPAs are warranted.