J Neurol Surg B Skull Base 2023; 84(01): 008-016
DOI: 10.1055/s-0041-1741017
Original Article

Volumetric Resection and Complications in Nonfunctioning Pituitary Adenoma by Fully Endoscopic Transsphenoidal Approach along 15 Years of Single-Center Experience

1   Department of Neurosurgery, La Paz University Hospital, Madrid, Spain
,
Miguel Sáez Alegre
1   Department of Neurosurgery, La Paz University Hospital, Madrid, Spain
,
Catalina Vivancos Sanchez
1   Department of Neurosurgery, La Paz University Hospital, Madrid, Spain
,
Alvaro Zamarrón Pérez
1   Department of Neurosurgery, La Paz University Hospital, Madrid, Spain
,
1   Department of Neurosurgery, La Paz University Hospital, Madrid, Spain
› Author Affiliations

Abstract

Objective The aim of this study was to evaluate the rate of complications and the extent of resection (EOR) of nonfunctioning pituitary adenomas by endoscopic endonasal approach (EEA) in a 15-year learning curve.

Methods A total of 100 patients operated by the same surgical team were divided chronologically into two, three, and four groups, comparing differences in EOR measured by a semiautomatic software (Smartbrush, Brainlab), rate of immediate postoperative complications, and the visual and hormonal status at 6 months.

Results There were no significant differences over the years in rates of postoperative complications and in visual status at 6 months. A significant linear correlation between the EOR and the number of surgeries (rho = 0.259, p = 0.007) was found. The analysis was performed in three groups because of the remarkable differences among them; the EOR were: 87.2% (early group), 93.03% (intermediate group), and 95.1% (late group) (p = 0.019). Gross total resection was achieved in 30.3, 51.5, and 64%, respectively (p = 0.017); also, the rate of reoperation and the worsening of at least one new hormonal axis were worse in the early group. Consequently, the early group had a higher risk of incomplete resection compared with the late group (odds ratio: 4.2; 95% confidence interval: 1.5–11.7). The three groups were not different in demographic and volume tumor variables preoperatively.

Conclusions The first 33 interventions were associated with a lower EOR, a high volume of residual tumor, a high reoperation rate, and a higher rate of hormonal dysfunction. We did not find differences in terms of postoperative complications and the visual status at 6-month follow-up.



Publication History

Received: 30 December 2020

Accepted: 12 November 2021

Article published online:
29 December 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Carrau RL, Jho H-D, Ko Y. Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 1996; 106 (07) 914-918
  • 2 Cavallo LM, Somma T, Solari D. et al. Endoscopic endonasal transsphenoidal surgery: history and evolution. World Neurosurg 2019; 127: 686-694
  • 3 Lucas JW, Bodach ME, Tumialan LM. et al. Congress of neurological surgeons systematic review and evidence-based guideline on primary management of patients with nonfunctioning pituitary adenomas. Neurosurgery 2016; 79 (04) E533-E535
  • 4 Fernandez-Miranda JC, Prevedello DM, Gardner P, Carrau R, Snyderman CH, Kassam AB. Endonasal endoscopic pituitary surgery: is it a matter of fashion?. Acta Neurochir (Wien) 2010; 152 (08) 1281-1282 , author reply 1282
  • 5 Shou X, Shen M, Zhang Q. et al. Endoscopic endonasal pituitary adenomas surgery: the surgical experience of 178 consecutive patients and learning curve of two neurosurgeons. BMC Neurol 2016; 16 (01) 247
  • 6 Gondim JA, Schops M, de Almeida JPC. et al. Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary 2010; 13 (01) 68-77
  • 7 Li A, Liu W, Cao P, Zheng Y, Bu Z, Zhou T. Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: a systematic review and meta-analysis. World Neurosurg 2017; 101: 236-246
  • 8 Akbari H, Malek M, Ghorbani M. et al. Clinical outcomes of endoscopic versus microscopic trans-sphenoidal surgery for large pituitary adenoma. Br J Neurosurg 2018; 32 (02) 206-209
  • 9 Little AS, Kelly DF, White WL. et al; TRANSSPHER Study Group. Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study. J Neurosurg 2019; 132 (04) 1043-1053
  • 10 Agam MS, Wedemeyer MA, Wrobel B, Weiss MH, Carmichael JD, Zada G. Complications associated with microscopic and endoscopic transsphenoidal pituitary surgery: experience of 1153 consecutive cases treated at a single tertiary care pituitary center. J Neurosurg 2018; 130 (05) 1-8
  • 11 Asemota AO, Ishii M, Brem H, Gallia GL. Comparison of complications, trends, and costs in endoscopic vs microscopic pituitary surgery: analysis from a US health claims database. Neurosurgery 2017; 81 (03) 458-472
  • 12 Younus I, Gerges MM, Uribe-Cardenas R. et al. How long is the tail end of the learning curve? Results from 1000 consecutive endoscopic endonasal skull base cases following the initial 200 cases. J Neurosurg 2020; 134 (03) 750-760
  • 13 Zaidi HA, Awad A-W, Bohl MA. et al. Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma. J Neurosurg 2016; 124 (03) 596-604
  • 14 Robins JMW, Alavi SA, Tyagi AK, Nix PA, Wilson TM, Phillips NI. The learning curve for endoscopic trans-sphenoidal resection of pituitary macroadenomas. A single institution experience, Leeds, UK. Acta Neurochir (Wien) 2018; 160 (01) 39-47
  • 15 Lofrese G, Vigo V, Rigante M. et al. Learning curve of endoscopic pituitary surgery: experience of a neurosurgery/ENT collaboration. J Clin Neurosci 2018; 47: 299-303
  • 16 Koc K, Anik I, Ozdamar D, Cabuk B, Keskin G, Ceylan S. The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev 2006; 29 (04) 298-305 , discussion 305
  • 17 Qureshi T, Chaus F, Fogg L, Dasgupta M, Straus D, Byrne RW. Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors. Br J Neurosurg 2016; 30 (06) 637-642
  • 18 Shikary T, Andaluz N, Meinzen-Derr J, Edwards C, Theodosopoulos P, Zimmer LA. Operative learning curve after transition to endoscopic transsphenoidal pituitary surgery. World Neurosurg 2017; 102: 608-612
  • 19 Vandenbroucke JP, von Elm E, Altman DG. et al; STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiology 2007; 18 (06) 805-835
  • 20 Esposito D, Olsson DS, Ragnarsson O, Buchfelder M, Skoglund T, Johannsson G. Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management. Pituitary 2019; 22 (04) 422-434
  • 21 Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 1993; 33 (04) 610-617 , discussion 617–618
  • 22 Sorensen AG, Patel S, Harmath C. et al. Comparison of diameter and perimeter methods for tumor volume calculation. J Clin Oncol 2001; 19 (02) 551-557
  • 23 Chuang CC, Lin SY, Pai PC. et al. Different volumetric measurement methods for pituitary adenomas and their crucial clinical significance. Sci Rep 2017; 7 (01) 40792
  • 24 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
  • 25 Ku CR, Hong JW, Kim EH, Kim SH, Lee EJ. Clinical predictors of GH deficiency in surgically cured acromegalic patients. Eur J Endocrinol 2014; 171 (03) 379-387
  • 26 Chanson P, Raverot G, Castinetti F, Cortet-Rudelli C, Galland F, Salenave S. French Endocrinology Society non-functioning pituitary adenoma work-group. Management of clinically non-functioning pituitary adenoma. Ann Endocrinol (Paris) 2015; 76 (03) 239-247
  • 27 Molitch ME. Diagnosis and treatment of pituitary adenomas: a review. JAMA 2017; 317 (05) 516-524
  • 28 Sam AH, Shah S, Saleh K. et al. Clinical outcomes in patients with nonfunctioning pituitary adenomas managed conservatively. Clin Endocrinol (Oxf) 2015; 83 (06) 861-865
  • 29 Sivakumar W, Chamoun R, Nguyen V, Couldwell WT. Incidental pituitary adenomas. Neurosurg Focus 2011; 31 (06) E18
  • 30 Scangas GA, Laws Jr ER. Pituitary incidentalomas. Pituitary 2014; 17 (05) 486-491
  • 31 Elshazly K, Kshettry VR, Farrell CJ, Nyquist G, Rosen M, Evans JJ. Clinical outcomes after endoscopic endonasal resection of giant pituitary adenomas. World Neurosurg 2018; 114: e447-e456
  • 32 Wang F, Zhou T, Wei S. et al. Endoscopic endonasal transsphenoidal surgery of 1,166 pituitary adenomas. Surg Endosc 2015; 29 (06) 1270-1280
  • 33 Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary 2014; 17 (04) 307-319
  • 34 Sanmillán JL, Torres-Diaz A, Sanchez-Fernández JJ. et al. Radiologic predictors for extent of resection in pituitary adenoma surgery. a single-center study. World Neurosurg 2017; 108: 436-446
  • 35 Cappabianca P, Cavallo LM, de Divitiis O, Solari D, Esposito F, Colao A. Endoscopic pituitary surgery. Pituitary 2008; 11 (04) 385-390
  • 36 Almutairi RD, Muskens IS, Cote DJ. et al. Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis. Acta Neurochir (Wien) 2018; 160 (05) 1005-1021
  • 37 Øystese KAB, Hisanawi S, Zucknick M, Bollerslev J, Ringstad G. Are volume measurements of non-functioning pituitary adenomas reliable?. Endocrine 2019; 63 (01) 171-176
  • 38 Micko A, Oberndorfer J, Weninger WJ. et al. Challenging Knosp high-grade pituitary adenomas. J Neurosurg 2019; 132 (06) 1739-1746
  • 39 Müslüman AM, Cansever T, Yılmaz A. et al. Surgical results of large and giant pituitary adenomas with special consideration of ophthalmologic outcomes. World Neurosurg 2011;76(1–2):141–148, discussion 63–66
  • 40 Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg 2013; 118 (03) 621-631
  • 41 Juraschka K, Khan OH, Godoy BL. et al. Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection. J Neurosurg 2014; 121 (01) 75-83
  • 42 Kim JH, Lee JHJH, Lee JHJH, Hong AR, Kim YJ, Kim YHYJ. Endoscopic transsphenoidal surgery outcomes in 331 nonfunctioning pituitary adenoma cases after a single surgeon learning curve. World Neurosurg 2018; 109: e409-e416
  • 43 Gerges MM, Rumalla K, Godil SS. et al. Long-term outcomes after endoscopic endonasal surgery for nonfunctioning pituitary macroadenomas. J Neurosurg 2020; ;(January): 1-12
  • 44 Dallapiazza RF, Grober Y, Starke RM, Laws Jr ER, Jane Jr JA. Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas. Neurosurgery 2015; 76 (01) 42-52 , discussion 52–53
  • 45 Levy MJ, Robertson IJ, Khalk N. et al. Long-term follow-up of a large prospective cohort of patients with nonfunctioning pituitary adenomas: the outcome of a conservative management policy. Clin Endocrinol (Oxf) 2018; 89 (03) 354-359
  • 46 Hughes JD, Koeller K, Rinaldo L. et al. Beyond gross total and subtotal: does volumetric resection matter in nonfunctioning pituitary macroadenomas?. World Neurosurg 2018; 116: e733-e737
  • 47 Dekkers OM, Pereira AM, Roelfsema F. et al. Observation alone after transsphenoidal surgery for nonfunctioning pituitary macroadenoma. J Clin Endocrinol Metab 2006; 91 (05) 1796-1801
  • 48 Kumar S, Darr A, Hobbs CG, Carlin WV. Endoscopic, endonasal, trans-sphenoidal hypophysectomy: retrospective analysis of 171 procedures. J Laryngol Otol 2012; 126 (10) 1033-1040
  • 49 Chi F, Wang Y, Lin Y, Ge J, Qiu Y, Guo L. A learning curve of endoscopic transsphenoidal surgery for pituitary adenoma. J Craniofac Surg 2013; 24 (06) 2064-2067
  • 50 Perry A, Graffeo CS, Meyer J. et al. Beyond the learning curve: comparison of microscopic and endoscopic incidences of internal carotid injury in a series of highly experienced operators. World Neurosurg 2019; 131: e128-e135
  • 51 Sonnenburg RE, White D, Ewend MG, Senior B. The learning curve in minimally invasive pituitary surgery. Am J Rhinol 2004; 18 (04) 259-263
  • 52 Leach P, Abou-Zeid AH, Kearney T, Davis J, Trainer PJ, Gnanalingham KK. Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve. Neurosurgery 2010; 67 (05) 1205-1212
  • 53 Jahangiri A, Wagner JR, Han SW. et al. Improved versus worsened endocrine function after transsphenoidal surgery for nonfunctional pituitary adenomas: rate, time course, and radiological analysis. J Neurosurg 2016; 124 (03) 589-595
  • 54 Laws Jr ER, Iuliano SL, Cote DJ, Woodmansee W, Hsu L, Cho CH. A benchmark for preservation of normal pituitary function after endoscopic transsphenoidal surgery for pituitary macroadenomas. World Neurosurg 2016; 91: 371-375
  • 55 O'Malley Jr BW, Grady MS, Gabel BC. et al. Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus 2008; 25 (06) E10
  • 56 Ding H, Gu Y, Zhang X. et al. Learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. J Clin Neurosci 2017; 42: 209-216
  • 57 Snyderman C, Kassam A, Carrau R, Mintz A, Gardner P, Prevedello DM. Acquisition of surgical skills for endonasal skull base surgery: a training program. Laryngoscope 2007; 117 (04) 699-705
  • 58 Kaplan DJ, Vaz-Guimaraes F, Fernandez-Miranda JC, Snyderman CH. Validation of a chicken wing training model for endoscopic microsurgical dissection. Laryngoscope 2015; 125 (03) 571-576
  • 59 Sanromán-Álvarez P, Simal-Julián JA, García-Piñero A, Miranda-Lloret P. Multitask box trainer for endoscopic endonasal skull base surgery: ENDOtrainer. World Neurosurg 2017; 101: 304-307