Simultaneous versus Staged Combined Endoscopic Endonasal Approach for Resection of Complex Skull Base Tumors

Objective: The endoscopic endonasal approach has become the workhorse of central skull base surgery, allowing aggressive resections of lesions from the anterior cranial fossa to the craniocervical junction. However, some complex tumors arising from or extending into the central skull base may extend beyond the anatomical boundaries of this approach, requiring a second corridor to complement it. In this study, we analyzed the cases at our institution that required a combination of endonasal endoscopic approach with a transcranial approach, either simultaneously or as staged procedures.

Methods: Out of 570 cases of skull-base tumors which underwent an endoscopic endonasal or a transcranial approach by the senior author at our institution since 2018, 30 patients required a combined strategy. Patients were divided according to the timing of the combined approach; either simultaneous or staged. Lesions were classified according to pathology and the compartments they occupied. Primary endpoints were clinical outcomes, extent of resection, and postoperative complications in both groups.

Results: Twenty-three patients underwent a simultaneous strategy, and 7 patients underwent a staged strategy. Gross total resection was achieved in 7 patients (30.4%) in the simultaneous group and in 2 patients (28.6%) in the staged group (p = 0.848). Complications occurred in 4 out of 23 cases (17.4%) in the simultaneous group, and in 2 out of 7 cases (28.6%) in the staged group (p = 0.517). Neurological deficits improved in 6 out of 11 patients in the simultaneous group and in 1 out of 5 in the staged group ([Figs. 1] and [2]).

Conclusion: The use of a combined endoscopic endonasal–transcranial strategy for complex skull base tumors provides several benefits over their single components, such as safer manipulation of neurovascular structures. Our study showed that there were no significant differences between performing both approaches simultaneously or staged; therefore, selection of the strategy depends on the particular characteristics of the lesion, the surgical team, and the institution.

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Artikel online veröffentlicht:
05. Februar 2024