Download PDF
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

Alexis Palpan Flores 
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
,
Carlos Pérez-López 
1   Department of Neurosurgery, La Paz University Hospital, Madrid, Spain
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

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.

Keywords

nonfunctioning pituitary adenoma - learning curve - extent of resection - gross total resection - semiautomatic volumetry - transsphenoidal approach - endoscopic endonasal approach


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
    CrossrefPubMedGoogle Scholar
  • 2 Cavallo LM, Somma T, Solari D. et al. Endoscopic endonasal transsphenoidal surgery: history and evolution. World Neurosurg 2019; 127: 686-694
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Google Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Google Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 27 Molitch ME. Diagnosis and treatment of pituitary adenomas: a review. JAMA 2017; 317 (05) 516-524
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 29 Sivakumar W, Chamoun R, Nguyen V, Couldwell WT. Incidental pituitary adenomas. Neurosurg Focus 2011; 31 (06) E18
    CrossrefPubMedGoogle Scholar
  • 30 Scangas GA, Laws Jr ER. Pituitary incidentalomas. Pituitary 2014; 17 (05) 486-491
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 35 Cappabianca P, Cavallo LM, de Divitiis O, Solari D, Esposito F, Colao A. Endoscopic pituitary surgery. Pituitary 2008; 11 (04) 385-390
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 38 Micko A, Oberndorfer J, Weninger WJ. et al. Challenging Knosp high-grade pituitary adenomas. J Neurosurg 2019; 132 (06) 1739-1746
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar