Transsphenoidal removal of huge pituitary adenomas with marked suprasellar extension: Results with modified surgical technique

Abstract

a b s t r a c tObjective: A modified transsphenoidal technique to remove huge pituitary adenomas with marked suprasellar extension (4.5-8 cm of maximum diameter) is presented. Methods:The technique allowed to avoid the occurrence of a precocious descent of the suprasellar cisternal plane into the sellar plane during tumour removal and its related consequences (incomplete tumour removal, occurrence of cerebrospinal fluid leak, prolonged time of postoperative stay in hospital). Technique is performed opening at the beginning only the lateral parts of peritumoral dura mater, leaving the central part of the dura mater in support of the central part of tumour and suprasellar cisternal plane. After removal of lateral parts of the tumour, the central part of peritumoral dura mater is opened and the central intra-and supra-sellar parts of the tumour are removed. Results: Total removal was accomplished in 64% and 45% in groups two and one respectively. Intraoperative CSF leak occurred in 2.4% and 22.5% respectively in groups two and one. Postoperative CSF fistula did not occur in group two, while it occurred in 7.4% of patients of group one. Average time of postoperative stay in hospital was 4.3 and 8.2 days in groups two and one respectively. Conclusion: The presented modified transsphenoidal microsurgical technique for removal of huge pituitary adenomas allowed to achieve better results than patients operated by standard transsphenoidal surgery.

Huge Pituitary Adenomas: Dedicated Surgical Technique and Indications for Extent of Tumour Removal in the Modern Era

“…Considering that adenomas of this series were invasive, and of large size, our therapeutic strategy was to remove tumor as most as possible, avoiding to remove invasive tumoral component strictly connected to crucial neurovascular structures, which are often encased into the tumor; hazardous maneuvers were avoided, such as other authors reported for other benign tumors of sellar-suprasellar compartment [3]. In the cases of huge invasive adenomas with involvement of optic chiasm, A1 tracts of anterior cerebral arteries and diencephalus crossed the tumors and were not above displaced (Figures 3 and 4): we programmed a staged transsphenoidal surgery, as other authors [4], programming the second stage when the tumor remnant would had been descended into the sellar cave. In order to perform the second programmed stage, neuronavigator was employed, as previously described, because anatomical landmarks could have become unclear because of the previous operation.…”