Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients

Abstract

BackgroundThe endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve.Material and MethodsAll patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records.ResultsMedian follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015).ConclusionThe EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.

Radiological Knosp, Revised-Knosp, and Hardy–Wilson Classifications for the Prediction of Surgical Outcomes in the Endoscopic Endonasal Surgery of Pituitary Adenomas: Study of 228 Cases

“…Another important aspect to consider during pituitary surgery is complications. As previously reported ( 49 , 50 ), we observed a higher proportion of surgical complications as higher Knosp grade of the PA. It is known that PAs invading the cavernous sinus are particularly surgically challenging due to their close proximity to critical neurovascular structures and their deep intracranial location.…”

Diagnostic Value of Non-Contrast CT in Cerebrospinal Fluid Leakage After Endoscopic Transnasal Surgery for Sellar and Suprasellar Tumors

“…We found that the NP change after expansive sponge extraction could better predict p-CFL than the first-day NP. Previous studies considered post-operative NP as an epiphenomenon of intra-operative CSF leak which would correlate with a higher risk of p-CFL ( 31 , 32 ). Head NCCT examination was routinely performed on the first day after operation when the patient’s bilateral nasal cavity was filled with an expansive sponge, and they were in a continuous supine position.…”

Identification of the Extradural and Intradural Extension of Pituitary Adenomas to the Suprasellar Region: Classification, Surgical Strategies, and Outcomes

“…The transsphenoidal approach is more appropriate for grade 1a PAs. However, we preferred EEA, owing to its advantages including wide-angle view and elimination of brain retraction (12,14,(29)(30)(31). Special attention should be given to protect the residual pituitary gland intraoperatively.…”