Improved Surgical Safety via Intraoperative Navigation for Transnasal Transsphenoidal Resection of Pituitary Adenomas

Abstract

Objectives Intraoperative navigation during neurosurgery can aid in the detection of critical structures and target lesions. The safety and efficacy of intraoperative, stereotactic computed tomography (CT) in the transnasal transsphenoidal resection of pituitary adenomas were explored. Design Retrospective chart review Setting Tertiary care hospital Participants Patients who underwent transsphenoidal resection of pituitary adenomas from February 2002 to May 2017. Intraoperative stereotactic CT navigation was used for all patients after mid-October 2013. Main Outcome Measures Operative time, estimated blood loss, gross total resection rate. Results Of 634 patients included, 175 underwent surgery with intraoperative navigation and 444 had no intraoperative navigation during surgery. There was no difference in mean age, sex, tumor type, or tumor size between the two groups. Operative time, endoscope use, cerebrospinal fluid diversion, and estimated blood loss were also similar. Two patients showed intraoperative, iatrogenic misdirection in the absence of stereotactic CT navigation ( p = 0.99) but similar numbers of patients having navigated and non-navigated surgery returned to the operating room, underwent gross total resection, and showed endocrinological normalization. Conclusions These results suggest that intraoperative navigation can reduce injury without resulting in increased operative time, estimated blood loss, or reduction in gross total resection.

Keywords: image guidance; navigation; pituitary adenoma; transsphenoidal approach.

Fig. 1

Case 1. Patient with iatrogenic skull base injury who was treated before implementation of stereotactic computed tomography navigation. ( A ) Coronal T1-weighted images with contrast enhancement of a 70-year-old male patient who underwent transsphenoidal microsurgical resection of an incidentally discovered pituitary macroadenoma are shown. Incorrect intraoperative localization resulted in injury to the left cavernous segment of the internal carotid artery within the opticocarotid recess. ( B , C ) An X-ray image and three-dimensional (3D) reconstruction of a left orbital view postoperative angiogram shows a 1-mm pseudoaneurysm. ( D , E ) A follow-up X-ray angiogram and 3D reconstruction on postoperative day 7 shows resolution of the pseudoaneurysm. The patient was discharged on postoperative day 15. (F) Postoperative imaging showed expected residual disease, which was stable at up to 4-year follow-up.

Fig. 2

Case 2. Patient with an iatrogenic skull base injury treated before implementation of stereotactic CT navigation ( A ) Axial and ( B ) coronal T1-weighted images with contrast enhancement of a 51-year-old female patient who underwent transsphenoidal microsurgical resection of a pituitary macroadenoma that initially presented incidentally. Intraoperatively, placement of the fixed speculum was aimed superiorly, because of incorrect distinction between the superior and middle turbinates, resulting in a fracture of the cribriform plate and a cerebrospinal fluid leak (image not available). The patient was treated with a lumbar drain for 3 days and discharged on postoperative day 6 uneventfully. ( C ) An axial T1-weighted image with contrast enhancement at 2 years postoperatively shows no residual or recurrent disease. The patient has been monitored for 4 years with no residual or recurrent disease.