Endoscopic transsphenoidal surgery for resection of pituitary macroadenoma: A retrospective study

Abstract

Background: The endoscopic transsphenoidal approach is an efficient minimally invasive procedure for removal of pituitary tumors that can be accomplished through a one-hand or two-hand approach. The one-hand procedure through one nostril is more intuitive for surgeons, but maneuvering the instruments can be restrictive. The two-hand procedure using a one-and-half nostril approach provides more precise manipulation. This study aimed to compare the surgical outcomes of one-hand/mono-nostril and two-hand/one-and-half nostril surgeries for resection of large pituitary tumors by a single neurosurgeon.

Materials and methods: The surgical data of 78 consecutive cases with pituitary macroadenoma (diameter >1 cm) were reviewed retrospectively. Altogether, 30 cases received one-hand/mono-nostril surgery, while 48 cases received two-hand/one-and-half nostril surgery. Postoperative outcomes of the two operations were compared.

Results: The operative time, hospital stay, residual rate of pituitary macroadenoma, visual field, surgical complications, and re-operative rates were slightly improved in the two-hand/one-and-half nostril surgery group compared with that in the one-hand/mono-nostril surgery group (all p>0.05). However, postoperative hypopituitarism was less frequent (1/48; 2.0%) with the two-hand/one-and-half nostril approach than with the mono-nostril approach (p = 0.004). Similar surgical outcomes were found in all patients with either small or large pituitary tumors, except that the difference in postoperative improvement in visual field change reached statistical significance (p = 0.044).

Conclusion: A single-surgeon endoscopic endonasal transsphenoidal surgery with two-hand/one-and-half nostril approach is an effective and safe procedure for removal of large pituitary tumors.

Fig 1

One-hand (A) and two-hand (B) technique surgical views. (A) The one-hand/mono-nostril operation for treatment of pituitary tumors was performed through the right nostril with one hand holding the endoscope (filled triangle) and the other hand using the surgical instruments. (B) The two-hand/one-and-half nostril surgery was assisted by an endoscope holder (arrow). All techniques employed in two-surgeon endoscopic surgery are incorporated into this approach.

Fig 2. Illustration of surgical approach.

(A) The one-hand operation was done through the right nostril with one hand holding the endoscope and the other hand using the surgical instruments. The middle turbinate was pushed laterally to expose the ostium of the sphenoid sinus. A naso-septal flap was created before the sphenoidectomy in selected cases. The sphenoidectomy was performed by widening the ostium with partial removal of the vomer bone. (B) The two-hand/one-and half nostril approach shared a similar surgical approach. After the exposure of the sphenoid sinus, the distal end of the nasal septum was opened for the contralateral nostril approach. The endoscope was then held by the holder, and the opening of the sellar floor and the removal of the tumor was performed by two-hand manipulation. The images were copied from website (https://www.kenhub.com/en/start/medial-wall-of-nasal-cavity) and further modified.