Endoscopic transsphenoidal approach through a widened nasal cavity for pituitary lesions

Endoscopic versus Microscopic Pituitary Adenoma Surgery: An Institutional Experience

AIM

The aim of this study was to compare the efficacy of endoscopic versus microscopic excision of pituitary adenoma, and to evaluate the merits and demerits of each approach.

MATERIALS AND METHODS

Prospective data were collected and patients were surgically treated for pituitary adenoma at SMS Hospital, Jaipur, Rajasthan, India. Patients consent was obtained. Age, sex, presenting symptoms, length of hospital stay, pre- and post-operative hormone status, extent of resections of tumors, and intra- and post-operative complication were noted.

RESULTS

A total of thirty patients with pituitary adenoma were operated transsphenoidally. Seventeen patients were operated by endonasal endoscopic transsphenoidal surgery and 13 patients were operated by microscopic transsphenoidal surgery. In an endoscopic group, complete tumor excision was achieved in 11 (64.71%) patients, and in microscopic group, it was achieved in 6 (46.15%) patients. In endoscopic group, mean operative time was 111.29 ± 21.95 min (ranged 80-135 min), and in microscopic group, it was 134.38 ± 8.33 min (ranged 120-145 min). In endoscopic group, mean blood loss was 124.41 ± 39.64 ml (60-190 ml), and in microscopic group, it was 174.62 ± 37.99 (100-220 ml). Postoperative sinusitis was present in 1 (5.88%) patient in endoscopic group and in 2 (15.38%) patients in microscopic group.

CONCLUSION

Endoscopic approach provides a wide surgical field and broad lateral vision making easier distinction of tumor tissues. Thus, there is less blood loss, greater extent of tumor removal and it had less operative time, less postoperative complication, and early discharge from the hospital.

Feasibility of endoscopic endonasal approach for recurrent pituitary adenomas after microscopic trans-sphenoidal approach

OBJECTIVE

The surgical approach for recurrent pituitary adenoma after trans-sphenoidal approach (TSA) is challenging. We report the outcomes of the endoscopic TSA for recurrent pituitary adenoma after microscopic TSA.

METHODS

From February 2010 to February 2013, endoscopic TSA was performed for removal of 30 recurrent pituitary adenomas after microscopic TSA. Twenty-seven (90%) patients had a clinically non-functioning pituitary adenoma. Twenty-four (80%) patients suffered from a visual disturbance related to tumor growth. The clinical features and surgical outcomes were retrospectively analyzed for the ophthalmological, endocrinological, and oncological aspects.

RESULTS

The mean tumor volume was 11.7 cm(3), and gross total resection was achieved in 50% of patients. The volumetric analysis based on the postoperative MR showed that the mean extent of resection rates were 90%. Vision was improved in 19 (79%) of 24 patients with visual symptoms, and endocrinological cure was achieved in all of three functioning pituitary adenomas; however, the post-operative follow-up endocrinological examination revealed a new endocrinological deficit in one patient. Two patients required antibiotics management for post-operative meningitis.

CONCLUSION

The endoscopic TSA can be an effective treatment option for recurrent pituitary adenoma after microscopic TSA with acceptable outcome.

A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.

Excision of pituitary adenomas: randomized comparison of surgical modalities

The aim of this randomized prospective study was to compare the efficacy of endoscopic versus standard microsurgical excision of pituitary adenomas, and to evaluate the merits and demerits of each approach. Twenty patients with a pituitary adenoma were randomly divided into two groups comprising of 10 cases each. Ten cases were operated by endoscopic endonasal trans-sphenoidal approach by endoscopic rhinologist (EETSS group) and other 10 cases were excised by microsurgical endonasal trans-sphenoidal approach by a neurosurgeon (SMETSS group). In both the groups complete excision was achieved in 50% of patients (unpaired t-test, p = 1.00). In EETSS group mean operative time was 64.5 +/- 19.16 min (range 50 - 100 min). In the SMETSS group, mean operative time was 75.5 +/- 18.48 min (range 55 - 120 min; unpaired t-test, p = 0.64, statistically not significant). In the EETSS group blood loss ranged between 100 and 190 ml (mean 100 +/- 42.16 ml). In the SMETSS group blood loss ranged between 50 and 250 ml (mean loss of 120 +/- 58.69 ml; unpaired t-test, p < 0.05, statistically significant). Postoperative nasoseptal complications were more common in SMETSS group (Chi-square test, p < 0.05, statistically significant). Endoscopic approach provides a wide surgical field and broad lateral vision making easier distinction of tumour tissue: gland and gland diaphragm interface. Thus, there is less blood loss and nasoseptal complications, whereas there was no statistically significant difference in operative time and complete tumour removal.