Endoscopic Transsphenoidal Approach for Pituitary Tumors

The purpose of this study is to demonstrate the benefits of and to relate our experience with endoscopic-assisted transsphenoidal surgery of pituitary tumors. From 1999 to 2007, 103 patients (61 male, 42 female) ranging in age from 21 to 76 years old (median, 48 years) with sellar tumors were treated at the Brazilian Air Force Hospital and Hospital Universitário Antonio Pedro. The patients were placed in the supine position with the head turned toward the neurosurgeon. The tumors were removed through a binostril transnasal direct approach using a 4-mm rigid 0- and 300-degree endoscope without working channel. Hemostatics were used to pack the sellar floor. Two-stage surgery was performed in 21 patients with giant adenomas. Chiasmatic decompression was achieved in the majority. Sixty-seven patients had macroadenomas and 36 microadenomas (69 nonfunctioning tumors, 17 GH-hormone secreting, 10 adrenocorticotropic tumors, and 7 nonpituitary tumors). Eleven of 17 acromegalic patients had resolution of their symptoms. Six patients developed CSF leak, four of them treated with subarachnoid lumbar drainage, and two required reoperation. Endoscopic transsphenoidal surgery provides a fast and safe approach to the sella, improves the surgical view, and has become our first option to reach sellar tumors.

Methods: Sixty-eight patients undergoing 71 operations to decompress 87 optic nerves were identified between 1991 and 2007. Thirty-four were through a transzygomatic and 37 through a transbasal approach. Fifty-two had meningiomas, four pituitary adenomas, three craniopharyngiomas, three chordomas, three adenocarcinomas, two fibrous dysplasia. Visual acuity and fields were recorded preoperatively, immediately postoperatively, at first follow-up, and at most recent follow-up.

Results: Forty-three eyes (49.4%) experienced an improvement in either acuity or fields. Twenty-four (27.5%) were unchanged and 20 (22.9%) deteriorated. Average improvement was 0.88 Snellen lines (logMAR 0.13). Improvement was seen between immediate postoperative acuity and first follow-up in 52%, but there was late deterioration between first follow-up and follow-up more than 12 months later in 22%. There was no relationship between age, duration of symptoms, pathology, approach, or redo surgery and visual outcome. There was a complex relationship between preoperative visual acuity and outcome. Although the postoperative acuity was closely correlated with the preoperative acuity, eyes with poor preoperative acuity experienced a larger average improvement. The odds of improving were uniform among eyes 6/60 or better but worse in eyes worse than 6/60 preoperatively.

Conclusions: Patients experience a significant benefit from optic nerve decompression irrespective of preoperative visual status. This is seen in all pathologies and approaches and does not correlate with age or symptom duration.