Correlates of prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenomas: varying definitions and non-clinical factors

PURPOSE

Prolonged length of stay (PLOS) can lead to resource misallocation and higher complication risks. However, there is no consensus on defining PLOS for endoscopic transsphenoidal pituitary surgery (ETPS). Therefore, we investigated the impact of varying PLOS definitions on factors associated with PLOS in patients undergoing ETPS.

METHODS

We conducted a retrospective review of patients with pituitary adenomas who underwent ETPS at our institution from 2012 to 2023. Patients were divided into non-PLOS and PLOS groups based on varying definitions of PLOS: > median, > 4 days, > 75th percentile, and > 90th percentile. Bivariate statistical analyses were conducted using Fisher's exact test, chi-square test, and t-tests. Univariate and multivariate logistic regression identified significant predictors for each PLOS definition.

RESULTS

Our cohort (n = 808) had a mean age of 54.37 ± 16.06 years, 50.43% male, and a median LOS of 3 days. The 75th and 90th percentiles of LOS were 4 and 6 days, respectively. The way PLOS was defined influenced associated factors identified. Preoperative KPS score, non-private insurance, and non-home discharge disposition were associated with PLOS across all definitions used (p < 0.05). Increased preoperative tumor volumes and postoperative hyponatremia were associated with PLOS only when defined by the 75th and 90th percentiles (p < 0.05). Non-White race and low income were significantly associated with PLOS > median while intraoperative CSF leak was a significant predictor for PLOS > 90th percentile (p < 0.05).

CONCLUSION

Our study highlights the variability in predictors of PLOS based on its definition and emphasizes the role of non-clinical factors on LOS.

γ-aminobutyric acid receptor B signaling drives glioblastoma in females in an immune-dependent manner

Sex differences in immune responses impact cancer outcomes and treatment response, including in glioblastoma (GBM). However, host factors underlying sex specific immune-cancer interactions are poorly understood. Here, we identify the neurotransmitter γ-aminobutyric acid (GABA) as a driver of GBM-promoting immune response in females. We demonstrated that GABA receptor B (GABBR) signaling enhances L-Arginine metabolism and nitric oxide synthase 2 (NOS2) expression in female granulocytic myeloid-derived suppressor cells (gMDSCs). GABBR agonist and GABA analog promoted GBM growth in females in an immune-dependent manner, while GABBR inhibition reduces gMDSC NOS2 production and extends survival only in females. Furthermore, female GBM patients have enriched GABA transcriptional signatures compared to males, and the use of GABA analogs in GBM patients is associated with worse short-term outcomes only in females. Collectively, these results highlight that GABA modulates anti-tumor immune response in a sex-specific manner, supporting future assessment of GABA pathway inhibitors as part of immunotherapy approaches.

The safety, accuracy, and feasibility of robotic assistance in neuro-oncological surgery

OBJECTIVE

Over the past 3 decades, robotic technology has advanced significantly across surgical fields, driven by improvements in versatility, stability, skill, and tactile properties. Neurosurgery has led the way in integrating robotics to improve the accuracy and safety of procedures that require high precision. This study aimed to present one of the largest series in the literature and investigate the feasibility and effectiveness of robotic assistance in neuro-oncological surgery.

METHODS

The authors performed a retrospective review of the medical records of patients who underwent stereotactic biopsy only and biopsy and laser interstitial thermal therapy (LITT) using the Robotic Surgical Assistant (ROSA) system. The ROSA system was used for trajectory planning as well as the precise alignment and insertion of the needle and/or laser catheter. All procedures were performed by a single neurosurgeon. Electronic medical records were reviewed for patient demographics, preoperative clinical deficits, diagnosis, preoperative and postoperative MR images, lesion characteristics including location and volume, postoperative complications, and deficits.

RESULTS

A total of 348 patients were identified. The mean age at surgery was 61.4 years, with 171 (49.1%) females. The most common presentations were GBM (40.5%, n = 141), metastasis (16.4%, n = 57), and radiation necrosis (9.8%, n = 34). A total of 189 (54%) patients underwent stereotactic biopsy only, and 159 (46%) underwent biopsy and LITT. The diagnostic yield of the cases was 98.6%, with only 5 cases having inconclusive pathology. Two (0.6%) patients experienced postoperative complications that resolved during follow-up. Ten (2.9%) patients developed asymptomatic subcentimeter hematomas following the procedure that did not require further intervention. No long-term consequences or permanent deficits occurred in any case within a median follow-up duration of 4.4 months (IQR 1-11.2 months).

CONCLUSIONS

These results indicate that a robot-assisted approach for stereotactic biopsies and LITT is associated with a comparable diagnostic yield and safety profile for frameless and frame-based techniques. Its precision, user-friendly interface, and adaptability contribute to its suitability for such procedures. Future research, especially in long-term results and cost-effectiveness, will be crucial in fully understanding the utility and potential of this technology for broader applications in the field.

Impact of insurance on outcomes of patients undergoing endoscopic transsphenoidal surgery for non-functional pituitary adenomas: a single institution study

PURPOSE

Uninsured and underinsured patients face notable healthcare disparities in neurosurgery, but limited literature exists on the impact of insurance on non-functioning pituitary adenomas (NFPAs). We investigated how insurance affects outcomes of endoscopic transsphenoidal pituitary surgery (ETPS) for NFPAs.

METHODS

We retrospectively reviewed NFPA patients who underwent ETPS at our institution from 2012 to 2023. Patients were grouped by insurance status, and insured patients were further subcategorized by insurance providers. Bivariate analyses used Fisher's exact, chi-square, and t-tests. ANOVA or Kruskal-Wallis tests were applied for ≥ 2 groups. Logistic regression identified relationships between binomial variables and insurance.

RESULTS

Our cohort (n = 651, 56.93 ± 15.53 years, 52.53% male) included 611 insured and 40 uninsured patients. Uninsured patients had lower preoperative KPS, higher rates of visual disturbances (VD), preoperative tumor volumes (TV), chiasm compression, and Knosp 4 grade, along with lower resection and longer hospital stays (LOS) (p < 0.05). Multivariate analysis showed lack of insurance was associated with increased VD (aOR 3.38), TV (aOR 2.63), Knosp 4 (aOR 3.44), subtotal resection (aOR 2.72), and prolonged LOS (aOR 7.03) (p < 0.05). When insured patients were grouped into Private (n = 361), Medicare (n = 223), and Medicaid (n = 23), Medicaid patients had larger preoperative TV, chiasm compression, Knosp 3 grade, and longer LOS (p < 0.05), with higher odds for Knosp 3 (aOR 3.00), subtotal resection (aOR 3.86), and prolonged LOS (aOR 8.38) (p < 0.05).

CONCLUSION

Our study highlights significant disparities in uninsured patients and those with Medicaid, underscoring the need for targeted interventions for these populations.

Optimizing outpatient neurosurgery: evaluating ambulatory surgery and same-day discharge following intracranial tumor surgery and endoscopic third ventriculostomy

OBJECTIVE

Outpatient surgery and same-day discharge are developing fields that align with the evolving needs of modern healthcare, presenting a notable advantage by reducing patient susceptibility to nosocomial infections, thromboembolic complications, and medical errors. When paired with enhanced recovery after surgery protocols, they hold promise in safely transitioning certain patients undergoing cranial surgery to outpatient care. This study aimed to evaluate discharge on the same day of surgery after intracranial tumor resection and endoscopic third ventriculostomy (ETV) and to investigate potential associations with anesthesia methods, complications, and readmission rates.

METHODS

A retrospective analysis of patients scheduled for planned discharge on the same day of surgery between August 2020 and October 2023 was conducted. Data included patient demographic characteristics, preoperative clinical deficits, diagnosis, findings on preoperative and postoperative MRI, lesion characteristics, complications, and readmission rates.

RESULTS

A total of 202 patients were included in the study. The mean age was 56.8 years and 117 (57.9%) patients were female. Patients were admitted the evening before surgery to obtain preoperative clearance and undergo MRI. The most common diagnoses were metastasis (23.3%), meningioma (20.8%), glioblastoma (12.4%), and low-grade glioma (10.4%). Craniotomy (46.5%), stereotactic needle biopsy (35.1), and ETV (6.9%) were the most common procedures performed. Thirteen (6.4%) patients underwent awake craniotomy, and 189 (93.6%) surgical procedures were conducted under general anesthesia. Complications occurred in 1.5% of patients, with no permanent complications observed during a mean follow-up of 9.3 months. In total, 179 (88.6%) patients were successfully discharged on the same day of surgery. The median length of hospitalization was 26.8 hours, with the median length of postoperative stay being 7 hours. Twenty-three (11.4%) patients were deemed ineligible for discharge on postoperative day 0 and instead discharged on postoperative day 1. The reasons for these delays included further clinical monitoring (n = 12), social factors (n = 4), and patient preference (n = 7). Age was positively correlated with length of hospitalization (p = 0.006). In total, 6.4% of patients were readmitted within 1-30 days after discharge, with 2.5% readmitted to the department of neurosurgery.

CONCLUSIONS

This study demonstrates the safety and feasibility of discharge on the same day of surgery, with a high success rate and low complication rates. Early discharge did not increase morbidity or readmission rates. Implementation of clear discharge protocols and thorough patient education are crucial for successful same-day discharge programs in neurosurgery.