Preliminary Comparison of the Endoscopic Transnasal vs the Sublabial Transseptal Approach for Clinically Nonfunctioning Pituitary Macroadenomas

Sheehan, Michael T.; Atkinson, John L.D.; Kasperbauer, Jan L.; Erickson, Bradley J.; Nippoldt, Todd B.

doi:10.4065/74.7.661

Cited by 121 publications

(86 citation statements)

References 22 publications

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“…Reported GTR rates range between 44% 44 and 88%. 12 In series adopting endoscopy and iMRI, GTR rates achieved at the iMRI have been reported to be much lower, ranging from as low as 34% and 41% 7,19,48 to as high as 62%.…”

Section: Discussion Resection Resultsmentioning

confidence: 99%

Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging

Serra¹,

Burkhardt²,

Esposito³

et al. 2016

FOC

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A lthough pituitary adenomas (PAs) are commonly classified as benign lesions, their clinical course is not always benign, and studies have confirmed that patients harboring a secreting adenoma have a reduced life expectancy, particularly those affected by adrenocorticotropic hormone (ACTH)-or growth hormone (GH)-secreting adenoma. 15,24,29,38,46 For such patients, endocrinological remission through gross-total resection (GTR) is the goal. Similarly, GTR is recommended for nonfunctioning pituitary adenomas (NFAs) requiring surgery, since subtotal resection (STR) and adenoma remnants after surgery have been repeatedly shown to represent a risk factor AbbreviAtioNs ACTH = adrenocorticotropic hormone; EOR = extent of resection; GH = growth hormone; GTR = gross-total resection; iMRI = intraoperative MRI; NFA = nonfunctioning pituitary adenoma; PA = pituitary adenoma; STR = subtotal resection; t = targeted; TSS = transsphenoidal surgery; TVDT = tumor volume doubling time. obJective The aim of this study was to quantitatively assess the role of intraoperative high-field 3-T MRI (3T-iMRI) in improving the gross-total resection (GTR) rate and the extent of resection (EOR) in endoscopic transsphenoidal surgery (TSS) for pituitary adenomas. methods Radiological and clinical data from a prospective database were retrospectively analyzed. Volumetric measurements of adenoma volumes pre-, intraoperatively, and 3 months postoperatively were performed in a consecutive series of patients who had undergone endoscopic TSS. The quantitative contribution of 3T-iMRI was measured as a percentage of the additional rate of GTR and of the EOR achieved after 3T-iMRI. results The cohort consisted of 50 patients (51 operations) harboring 33 nonfunctioning and 18 functioning pituitary adenomas. Mean adenoma diameter and volume were 21.1 mm (range 5-47 mm) and 5.23 cm 3 (range 0.09-22.14 cm 3 ), respectively. According to Knosp's classification, 10 cases were Grade 0; 8, Grade 1; 17, Grade 2; 12, Grade 3; and 4, Grade 4. Gross-total resection was the surgical goal (targeted [t]GTR) in 34 of 51 operations and was initially achieved in 16 (47%) of 34 at 3T-iMRI and in 30 (88%) of 34 cases after further resection. In this subgroup, the EOR increased from 91% at 3T-iMRI to 99% at the 3-month MRI (p < 0.05). In the 17 cases in which subtotal resection (STR) had been planned (tSTR), the EOR increased from 79% to 86% (p < 0.05) and GTR could be achieved in 1 case. Intrasellar remnants were present in 20 of 51 procedures at 3T-iMRI and in only 5 (10%) of 51 procedures after further resection (median volume 0.15 cm 3 ). Overall, the use of 3T-iMRI led to further resection in 27 (53%) of 51 procedures and permitted GTR in 15 (56%) of these 27 procedures; thus, the GTR rate in the entire cohort increased from 31% (16 of 51) to 61% (31 of 51) and the EOR increased from 87% to 95% (p < 0.05). coNclusioNs The use of high-definition 3T-iMRI allowed precise visualization and quantification of adenoma remnant volume. It helped to increase GTR and EOR rates in ...

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Section: Discussion Resection Resultsmentioning

confidence: 99%

Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging

Serra¹,

Burkhardt²,

Esposito³

et al. 2016

FOC

View full text Add to dashboard Cite

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“…4,24 Most have featured sequential series, 5,18 included very small numbers of patients, 4,22 or had other limitations that compromise the ability to compare the two approaches. Starke et al recently compared a large series of microscopic and endoscopic approaches for growth hormonesecreting tumors and found no difference in remission rates or postoperative complications.…”

Section: Discussionmentioning

confidence: 99%

“…Most previous studies have included a heterogeneity of tumor types, grouping together both functional and nonfunctional tumors. 5,18,22 Given that one of the principle arguments for using an endoscopic approach is that it allows a panoramic view of the sella and closer inspection of the posterior and superior recesses, it is important to compare the surgical outcomes for variously sized tumors. With this argument in mind, one might expect to see a correlation between the extent of tumor resection and Knosp grade or tumor volume.…”

Section: Discussionmentioning

confidence: 99%

“…Previous comparisons suggest that patients who undergo the endoscopic approach have shorter operative times, less operative blood loss, shorter hospitalizations, and fewer postoperative complications. 4,5,18,22 However, most of these studies have compared a prior microscopic series to a more recent endoscopic series or have included only small numbers of patients. No study has addressed whether one approach is superior for moderate-sized tumors without radiographic evidence of lateral extension into the cavernous sinus or has compared the outcomes of the two surgical approaches over the same interval.…”

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Retrospective analysis of a concurrent series of microscopic versus endoscopic transsphenoidal surgeries for Knosp Grades 0–2 nonfunctioning pituitary macroadenomas at a single institution

Dallapiazza¹,

Bond²,

Grober³

et al. 2014

JNS

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N eurosurgeoNs have traditionally used a sublabial or transseptal incision with an operating microscope to access the sphenoid sinus and sella turcica for the resection of pituitary tumors. 9 Over the past decade, however, the endoscopic endonasal transsphenoidal approach has become an increasingly popular method of removing pituitary tumors and other lesions of the sella. 2,3,7,12,20 Among the arguments proposed for the use of endoscopy for transsphenoidal surgery are that it provides a superior view of the sella and its surrounding structures by allowing panoramic visualization, and it offers improved lighting. Angled endoscopes allow visualization into recesses within the sphenoid sinus and sella that is not offered by the operating microscope. The enhanced visualization during endoscopic procedures theoretically can improve the extent of resection of very large pituitary tumors, in particular those extending laterally or superiorly beyond the direct vision of the operating microscope. On Object. The object of this study was to compare surgical outcomes and complications in a contemporaneous series of patients undergoing either microscopic or endoscopic transsphenoidal surgery for nonfunctioning pituitary macroadenomas without imaging evidence of cavernous sinus invasion.Methods. This is a retrospective analysis of a prospectively collected database from a single institution. Data were collected from patients whose surgery had occurred in the period from June 2010 to January 2013. Patients who underwent microscopic or endoscopic surgery for Knosp Grade 0, 1, or 2 nonfunctioning pituitary macroadenomas were included in the study. Patients who had clinically secreting or Knosp Grade 3 or 4 tumors and patients who were undergoing revision surgery were excluded from analysis. Eligible patient records were analyzed for outcomes and complications. Statistical analyses were performed on tumor volume, intraoperative factors, postoperative complications, and degree of resection on 1-year postoperative MRI. The results were used to compare the outcomes after microscopic and endoscopic approaches.Results. Forty-three patients underwent microscopic transsphenoidal surgery, and 56 underwent endoscopic transsphenoidal surgery. There were no statistical differences in the intraoperative extent of resection or endocrinological complications. There were significantly more intraoperative CSF leaks in the endoscopic group (58% vs 16%); however, there was no difference in the incidence of postoperative CSF rhinorrhea (12% microscopic vs 7% endoscopic). Length of hospitalization was significantly shorter in patients undergoing an endoscopic approach (3.0 days vs 2.4 days). Two-month follow-up imaging was available in 95% of patients, and 75% of patients had 1-year follow-up imaging. At 2 months postprocedure, there was no evidence of residual tumor in 79% (31 of 39) and 85% (47 of 55) of patients in the microscopic and endoscopic groups, respectively. At 1 year postprocedure, 83% (25 of 30) of patients in the microscopic group h...

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“…There have been a number of case series directly comparing endoscopic and microscopic surgical results by individual surgeons. 3,11,15,23,29,33 We describe our experience in conversion of a cranial base surgery program from traditional methods to the entirely endoscopic method of approach and resection for pituitary lesions. We compare 2 patient cohorts that underwent resection by the same senior neurosurgeon and otorhinolaryngologist (M.S.G.…”

Section: H Alsteadmentioning

confidence: 99%

Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve

O’Malley

Grady²,

Gabel³

et al. 2008

FOC

173

116

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Object The endoscopic endonasal approach for resection of pituitary lesions is an effective surgical option for tumors of the sella turcica. In this study the authors compared outcomes after either purely endoscopic resection or traditional microscope-aided resection. They also attempted to determine the learning curve associated with a surgical team converting to endoscopic techniques. Methods Retrospective data were collected on patients who were surgically treated for a pituitary lesion at the Hospital of the University of Pennsylvania between July 2003 and May 2008. Age, sex, race, presenting symptoms, length of hospital stay, surgical approach, duration of surgery, tumor pathological features, gross-total resection (GTR) of tumor, recurrence of the lesion, and intraoperative and postoperative complications were noted. All procedures were performed by the same senior neurosurgeon, who was initially unfamiliar with the endoscopic endonasal approach. Results A total of 25 patients underwent microscopic resection and 25 patients underwent endoscopic resection performed by a single skull base team consisting of the same senior neurosurgeon and otorhinolaryngologist (M.S.G. and B.W.O.). In the microscopically treated cohort, there were 8 intra- or postoperative complications, 6 intraoperative CSF leaks, 17 (77%) of 22 patients had GTR on postoperative imaging, 5 patients underwent ≥ 2 operations, and 10 (59%) of 17 patients reported total symptom resolution at follow-up. The endoscopically treated group had 7 intraor postoperative complications and 7 intraoperative CSF leaks. Of the patients who had pre- and postoperative imaging studies, 14 (66%) of 21 endoscopically treated patients had GTR; 4 patients had ≥ 2 operations, and 10 (66%) of 15 patients reported complete symptom resolution at follow-up. The first 9 patients who were treated endoscopically had a mean surgical time of 3.42 hours and a mean hospital stay of 4.67 days. The next 8 patients treated had a mean surgical time of 3.11 hours and a mean hospital stay of 3.13 days. The final 8 patients treated endoscopically had a mean surgical time of 2.22 hours and a mean hospital stay of 3.88 days. The difference in length of operation between the first 9 and the last 8 patients treated endoscopically was significantly different. There was a trend toward decreased CSF leaks and other complications from the first 2 groups compared with the third group. Conclusions In this subset of patients, the use of endoscopic endonasal resection results in a similar complication and symptom resolution rate compared with traditional techniques. The authors postulate that the learning curve for endoscopic resection can be ≤ 17 procedures.

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Preliminary Comparison of the Endoscopic Transnasal vs the Sublabial Transseptal Approach for Clinically Nonfunctioning Pituitary Macroadenomas

Cited by 121 publications

References 22 publications

Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging

Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging

Retrospective analysis of a concurrent series of microscopic versus endoscopic transsphenoidal surgeries for Knosp Grades 0–2 nonfunctioning pituitary macroadenomas at a single institution

Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve

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