Pituitary Surgery in Germany – Findings from the European Pituitary Adenoma Surgery Survey

Abstract

Background Surgery is, next to medical and radiation therapy, the mainstay therapy for pituitary adenomas. While scientific consensus regarding the key aspects of pituitary surgery exists among neurosurgeons, procedures are not standardized and might vary significantly between hospitals and surgeons.

Objective To provide an overview of how neurosurgical departments in Germany manage pituitary surgery.

Methods Responses from the European Pituitary Adenoma Surgery Survey were analyzed. The survey contained 60 questions regarding demographics, training, surgical and endocrinological aspects, and patient management.

Results Sixty neurosurgical centers from Germany responded to the survey. Among the centers, 35.3% (n=18) exclusively use the microscopic and 31.1% (n=14) the endoscopic technique; all other centers (n=28) use both approaches. Of responding centers, 20% (n=12) perform less than 10 transsphenoidal pituitary surgeries per year, and 1.7% (n=1), more than 100 operations. The number of transcranial pituitary operations is significantly smaller, with 53.3% of centers performing only 0–2 per year, 35% performing 3–5, and only one center (1.7%) performing more than 15 transcranial operations per year. In 8 centers (13.3%), surgeries are always performed together with an ENT surgeon; in 29 centers (48.4%) ENT surgeons are never involved. In most centers (n=54, 90%) intraoperative MRI is not available. Image guidance (with preoperative CT and/or MRI data) is used by 91.7% of respondents (n=55). Forty-two centers (72.4%) routinely prescribe hydrocortisone after pituitary surgery, and 75% (n=45) have pituitary board meetings with endocrinologists, radiologists, and radiosurgeons. Fifty-two (86.7%) respondents perform the first follow-up scan by MRI 3–4 months after surgery.

Conclusions The data showed differences as well as similarities between centers and could help to discuss the standardization of methods and the formation of networks and certification to improve patient care.

Key words

pituitary adenoma - pituitary surgery - survey

Publication History

Received: 06 December 2022
Received: 23 March 2023

Accepted: 19 March 2023
Accepted: 23 March 2023

Accepted Manuscript online:
23 March 2023

Article published online:
12 May 2023

• References

• 1 Schmidt RF, Choudhry OJ, Takkellapati R. et al. Hermann Schloffer and the origin of transsphenoidal pituitary surgery. Neurosurg Focus 2012; 33: 5
• 2 Hirsch O. Endonasal method of removal of hypophyseal tumors with report of two successful cases. JAMA 1910; 55: 772-774
• 3 Ottenhausen M, Bodhinayake I, Evins AI. et al. Expanding the borders: The evolution of neurosurgical approaches. Neurosurg Focus 2014; 36: 11
• 4 Kassam AB, Thomas A, Carrau RL. et. al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 6: 44-52
• 5 Greenfield JP, Howard BM, Huang C. et al. Endoscopic endonasal transsphenoidal surgery using a skull reference array and laser surface scanning. Minim Invasive Neurosurg 2008; 51: 244-246
• 6 Hlaváč M, Knoll A, Mayer B. et al. Ten years’ experience with intraoperative MRI-assisted transsphenoidal pituitary surgery. Neurosurg Focus 2020; 48: E14
• 7 Placantonakis DG, Tabaee A, Anand VK. et al. Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery. Neurosurgery 2007; 61: 161-165
• 8 Noh Y, Choi JE, Lee KE. et al. A comparison of olfactory and sinonasal outcomes in endoscopic pituitary surgery performed by a single neurosurgeon or a collaborative team of surgeons. Clin Exp Otorhinolaryngol 2020; 13: 261-267
• 9 Singh H, Essayed WI, Cohen-Gadol A. et al. Resection of pituitary tumors: Endoscopic versus microscopic. J Neurooncol 2016; 130: 309-317
• 10 Májovský M, Grotenhuis A, Foroglou N. et al. What is the current clinical practice in pituitary adenoma surgery in Europe? European Pituitary Adenoma Surgery Survey (EU-PASS) results-technical part. Neurosurg Rev 2022; 45: 831-841
• 11 Netuka D, Grotenhuis A, Foroglou N. et al. Endocrinological aspects of pituitary adenoma surgery in Europe. Sci Rep 2022; 12: 6529
• 12 Netuka D, Grotenhuis A, Foroglou N. et al. Pituitary adenoma surgery survey: Neurosurgical centers and pituitary adenomas. Int J Endocrinol 2022; 7206713
• 13 Ciric I, Ragin A, Baumgartner C. et al. Complications of transsphenoidal surgery: Results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40: 225-236
• 14 Barker FG, Klibanski A, Swearingen B. Transsphenoidal surgery for pituitary tumors in the United States, 1996-2000: Mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 2003; 88: 4709-4719
• 15 Casanueva FF, Barkan AL, Buchfelder M. et al. Criteria for the definition of Pituitary Tumor Centers of Excellence (PTCOE): A pituitary society statement. Pituitary 2017; 20: 489-498
• 16 McLaughlin N, Laws ER, Oyesiku NM. et al. Pituitary centers of excellence. Neurosurgery 2012; 71: 916-924
• 17 Van Gompel JJ, Atkinson JLD, Choby G. et al. Pituitary tumor surgery: Comparison of endoscopic and microscopic techniques at a single center. Mayo Clin Proc 2021; 96: 2043-2057
• 18 Goshtasbi K, Lehrich BM, Abouzari M. et al. Endoscopic versus nonendoscopic surgery for resection of pituitary adenomas: A national database study. J Neurosurg 2020; 134: 816-824
• 19 Ceylan S, Sen HE, Ozsoy B. et al. Endoscopic approach for giant pituitary adenoma: Clinical outcomes of 205 patients and comparison of two proposed classification systems for preoperative prediction of extent of resection. J Neurosurg 2021; 136: 786-800
• 20 Zacharia BE, Amine M, Anand V. et al. Endoscopic endonasal management of craniopharyngioma. Otolaryngol Clin North Am 2016; 49: 201-212
• 21 Kulwin C, Schwartz TH, Cohen-Gadol AA. Endoscopic extended transsphenoidal resection of tuberculum sellae meningiomas: Nuances of neurosurgical technique. Neurosurg Focus 2013; 35: 6
• 22 Ottenhausen M, Alalade AF, Rumalla K. et al. Quality of life after combined endonasal endoscopic odontoidectomy and posterior suboccipital decompression and fusion. World Neurosurg 2018; 116: 571-576
• 23 Ottenhausen M, Banu MA, Placantonakis DG. et al. Endoscopic endonasal resection of suprasellar meningiomas: The importance of case selection and experience in determining extent of resection, visual improvement, and complications. World Neurosurg 2014; 82: 442-449
• 24 Banu MA, Kim JH, Shin BJ. et al. Low-dose intrathecal fluorescein and etiology-based graft choice in endoscopic endonasal closure of CSF leaks. Clin Neurol Neurosurg 2014; 116: 28-34
• 25 Huo CW, King J, Goldschlager T. et al. The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery. J Clin Neurosci 2022; 98: 194-202
• 26 Caggiano C, Penn DL, Laws ER. The role of the lumbar drain in endoscopic endonasal skull base surgery: A retrospective analysis of 811 cases. World Neurosurg 2018; 117: 575-579