1. 3Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
Comparison of endoscopic vs microscopic techniques in primary transsphenoidal surgery for non-functioning pituitary macroadenomas
A. Saladino 1,2, R. Al-Mahfoudh 1, A. Patel 1, M. Lee 1, M. Javadpour 1,3
1 Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, Merseyside, UK
2 Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
3Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
Fig. 2
MTS
(n=17)
ETS
(n=30)
Lenght of operation (mins)
123.3 (SD±31.6)
126.4 (SD±37.2)
Hospital stay (days)
Mean
10.4 (SD±16.3)
5.7 (SD±3.48)
Median 5 4
Intraoperative CSF leak
3 (17.6%)
7 (23.3%)
Postoperative CSF leak (lumbar drain)
2 (11.8%)
1 (3.2%)
Visual field outcome
Improved
10 (58.8%)
12 (40%)
Stable
7 (41.2%)
18 (60%)
Postoperative haematoma
1 (5.9%)
1 (3.3%)
Background and aims
Endoscopic procedure: A binostril two-surgeon, four-hands technique was used . The patient was positioned supine with the head in a neutral position or slightly rotated towards the right side. The two surgeons were positioned on opposite sides of the table. After sterilization of the nasal mucosa, the endoscope was introduced at the “12 o’clock” position of the right nostril and was used to retract the nasal vestibule superiorly. The choana, the sphenoethmoid recess, the middle and superior turbinate are then identified as anatomical landmarks. The turbinates werevout-fractured if necessary to widen the surgical corridor. The natural ostium of the sphenoid sinus was identified and enlarged. The same procedure was performed in the opposite nostril. A posterior nasal septotomy was performed followed by a large sphenoidotomy and the removal of the bony rostrum completed using Kerrison rongeurs and/or surgical drill. The endoscope was then positioned at the “12 o’clock” position of the left nostril and held by the assistant (Fig 2).
Endoscopic transsphenoidal surgery (ETS) has gained popularity over microscopic transsphenoidal surgery (MTS). Previously published series often include heterogeneous groups of patients making comparison of techniques difficult. We compared the results of ETS and MTS in patients undergoing first-time surgery for non-functioning pituitary macroadenomas (NFPAs)
Methods
Information regarding patient demographics, operative technique, intra- and post-operative complications were obtained from a prospective database updated by the operating surgeon at the end of each surgical procedure and by the surgical team at the time of discharge. Information regarding clinical and radiological follow-up was obtained retrospectively.
Fig. 1
Results
Surgical tecnhique
Between June 2006 & June TS procedures were carried out for pituitary region tumours by a single surgeon. MTS was the technique used until June 2008 , and ETS after that date. Of the MTS group 17 patients underwent first time surgery for NFPA. These were compared with the first 30 patients in the ETS group undergoing first time surgery for NFPA. Mean length of operation was 123,3 (SD±31,6) and 126,4 (SD±37,2) minutes in group 1 and group 2, respectively. Mean and median hospital stay were 10.4 (SD±16,3) and 5 days in group 1 and 5.7 days (SD±3,48) and 4 days in group 2, with no statistically significant difference. Intraoperative CSF leak occurred in 3 (17.6%) and 7 (23.3%) patients. Post-operative CSF leak requiring lumbar drain occurred in 2 (11.8%) and 1 (3.2%) patients, respectively. Visual field was improved or stable in all patients in both groups at last follow-up (group 1: improved 10, stable 7; group 2: improved 12, stable 18). Post-operative haematoma (from residual tumour) requiring evacuation occurred in one case in each group. There were no deaths, carotid artery injury or visual loss in either group. Results are summarized in Table 1.
Microscopic procedure: The procedure was performed by a single surgeon through one nostril. The patient was positioned in supine position with the surgeon on his/her right side. After sterilization of the nasal mucosa, a long and narrow Killian nasal speculum was inserted in the right nostril over the middle turbinate. Based on preoperative CT scan, the speculum can be inserted in the left nostril if a convex, right-sided deviation of the nasal septum is present. A direct transnasal transsphenoidal approach was used. A Hardy’s retractor was inserted and the operation was performed under the surgical microscope (Fig. 1). At the end of the procedure the nasal cavities were packed with nasal tampons.
Table 1. Comparative results in the 2 groups
Conclusions
Despite a steep learning curve, ETS can be adopted by neurosurgeons with previous experience of MTS, without compromising on outcomes during the initial learning curve.