Comparison of Clinical Outcomes between Microscopic and Endoscopic Transsphenoidal Pituitary Tumor Resection

Abstract

Objectives In recent years, the transnasal endoscopic method for transsphenoidal pituitary tumor resection (eTSR), alongside the conventional sublabial microscopic transsphenoidal resection (mTSR) method, has gained popularity due to advancements in imaging and instrumentation. The current study sought to elucidate whether the trend toward eTSR was associated with changes in clinical outcomes at a single institution's multidisciplinary pituitary surgery program.

Setting and Participants The Virginia Commonwealth University (VCU) Brain Tumor Database was queried for patients who underwent either transnasal or sublabial pituitary tumor resection of pituitary tumors between 2009 and 2021.

Design Clinical outcomes were compared between the two groups.

Main Outcome Measures Surgical outcomes like estimated blood loss (EBL), cerebrospinal fluid (CSF) leak rates, hospital length of stay (LOS), and extent of resection were studied.

Results A total of 93 patients (57 mTSR, 36 eTSR) underwent review, revealing that mTSR was associated with a higher average intraoperative blood loss (310.5 ± 48.6 mL) than eTSR (160.0 ± 30.7 mL; p = 0.012). eTSR demonstrated an elevated intraoperative CSF leak incidence (36.1 vs. 15.8%; p = 0.043), but no difference in postoperative CSF leak requiring intervention. Hospital LOS and extent of resection showed no significant differences between the approaches.

Conclusion This single-institution, retrospective study suggests that, in experienced hands, both eTSR and mTSR approaches are effective with comparable risk profiles. The approach may be best determined by the surgical team's evaluation of the tumor's imaging features, paying attention to the patient's preoperative hematologic status due to the greater propensity for blood loss with the microscopic approach.

Keywords

transsphenoidal resection - microscope - endoscope - pituitary tumors - skull base

^* These authors contributed equally and share the first authorship.

Publikationsverlauf

Eingereicht: 28. November 2023

Angenommen: 14. Juni 2024

Artikel online veröffentlicht:
23. Juli 2024

• References

• 1 Khalafallah AM, Liang AL, Jimenez AE. et al. Trends in endoscopic and microscopic transsphenoidal surgery: a survey of the international society of pituitary surgeons between 2010 and 2020. Pituitary 2020; 23 (05) 526-533
• 2 Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery 2004; 54 (05) 1043-1048 , 1048–1050
• 3 Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2013; 84 (08) 843-849
• 4 Joshi SM, Cudlip S. Transsphenoidal surgery. Pituitary 2008; 11 (04) 353-360
• 5 Sethi DS, Leong JL. Endoscopic pituitary surgery. Otolaryngol Clin North Am 2006; 39 (03) 563-583 , x
• 6 Senior BA, Ebert CS, Bednarski KK. et al. Minimally invasive pituitary surgery. Laryngoscope 2008; 118 (10) 1842-1855
• 7 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
• 8 Prajapati HP, Jain SK, Sinha VD. Endoscopic versus microscopic pituitary adenoma surgery: an institutional experience. Asian J Neurosurg 2018; 13 (02) 217-221
• 9 Ogawa T, Matsumoto K, Nakashima T. et al. Hypophysis surgery with or without endoscopy. Auris Nasus Larynx 2001; 28 (02) 143-149
• 10 Guo-Dong H, Tao J, Ji-Hu Y. et al. Endoscopic versus microscopic transsphenoidal surgery for pituitary tumors. J Craniofac Surg 2016; 27 (07) e648-e655
• 11 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
• 12 Toda M, Kosugi K, Ozawa H, Ogawa K, Yoshida K. Surgical treatment of cavernous sinus lesion in patients with nonfunctioning pituitary adenomas via the endoscopic endonasal approach. J Neurol Surg B Skull Base 2018; 79 (Suppl. 04) S311-S315
• 13 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
• 14 Wachtel A. Recovery Guidelines for Pituitary Patients. Barrow Neurological Institute. Accessed March 13, 2024 at: https://www.barrowneuro.org/resource/recovery-guidelines-for-pituitary-patients/#:~:text=A%20typical%20hospital%20admission%20for
• 15 Thomas JG, Gadgil N, Samson SL, Takashima M, Yoshor D. Prospective trial of a short hospital stay protocol after endoscopic endonasal pituitary adenoma surgery. World Neurosurg 2014; 81 (3-4): 576-583
• 16 Lobatto DJ, Vliet Vlieland TPM, van den Hout WB. et al. Feasibility, safety, and outcomes of a stratified fast-track care trajectory in pituitary surgery. Endocrine 2020; 69 (01) 175-187
• 17 Gordon AJ, Dastagirzada Y, Schlacter J. et al. Health care disparities in transsphenoidal surgery for pituitary tumors: an experience from neighboring urban public and private hospitals. J Neurol Surg B Skull Base 2022; 84 (06) 560-566
• 18 Goljo E, Parasher AK, Iloreta AM, Shrivastava R, Govindaraj S. Racial, ethnic, and socioeconomic disparities in pituitary surgery outcomes. Laryngoscope 2016; 126 (04) 808-814
• 19 Kurosaki M, Lüdecke DK, Flitsch J, Saeger W. Surgical treatment of clinically nonsecreting pituitary adenomas in elderly patients. Neurosurgery 2000; 47 (04) 843-848 , discussion 848–849
• 20 Hussein M, Abdellatif M. Continuous lumbar drainage for the prevention and management of perioperative cerebrospinal fluid leakage. Asian J Neurosurg 2019; 14 (02) 473-478
• 21 Rajagopalan V, Chouhan RS, Pandia MP, Lamsal R, Rath GP. Effect of intraoperative blood loss on perioperative complications and neurological outcome in adult patients undergoing elective brain tumor surgery. J Neurosci Rural Pract 2019; 10 (04) 631-640
• 22 Chen Z, Ma Z, He W. et al. Impact of pituitary stalk preservation on tumor recurrence/progression and surgically induced endocrinopathy after endoscopic endonasal resection of suprasellar craniopharyngiomas. Front Neurol 2021; 12: 753944
• 23 Ogawa Y, Niizuma K, Tominaga T. Recovery from diabetes insipidus and preservation of thyroid function after craniopharyngioma removal and pituitary stalk sectioning. Clin Neurol Neurosurg 2017; 162: 36-40
• 24 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
• 25 Pei Z, Wang J, Mu S. et al. Microscopic transsphenoidal resection of giant pituitary adenomas: analysis of the factors limiting the degree of resection in 73 cases. Front Neurol 2022; 13: 880732
• 26 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
• 27 Yamamoto J, Kakeda S, Shimajiri S. et al. Tumor consistency of pituitary macroadenomas: predictive analysis on the basis of imaging features with contrast-enhanced 3D FIESTA at 3T. AJNR Am J Neuroradiol 2014; 35 (02) 297-303
• 28 Gaillard S, Adeniran S, Villa C. et al. Outcome of giant pituitary tumors requiring surgery. Front Endocrinol (Lausanne) 2022; 13: 975560
• 29 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