Safety and efficacy of the direct endonasal transsphenoidal approach for challenging sellar tumors

Introduction The direct endonasal approach to pituitary microadenomas is relatively atraumatic, rapid, and carries a lower complication rate than the sublabial approach. Large macroadenomas (3–4 cm) can still be addressed with this simple, unmodified direct endonasal approach. We present our experience with this unique and challenging patient population. Methods About 64 consecutive patients with large (3–4 cm) pituitary adenomas and craniopharyngiomas were treated by the senior author (SK) using the direct endonasal approach from May 2001 to July 2004. The hospital course, endocrinological function, radiographic imaging, and outpatient follow-up were retrospectively reviewed for each patient. Results The mean volume of these lesions was 31.5 cm³ (range, 10.3–168 cm³). Tumor pathologies included 2 craniopharyngiomas, 16 functional, and 46 nonfunctional pituitary adenomas. Suprasellar extension of tumor was evident in all patients and 10 had cavernous sinus invasion. Gross total resection was achieved in 30 patients, near-gross total in 6 patients, and subtotal resection in 26 patients. Eight patients (12.5%) demonstrated postoperative complications, with diabetes insipidus for less than 1 year (n = 4) being the most common. There was no incidence of CSF leak, new panhypopituitarism, or worsened vision. Five patients (7.8%) had tumor residual requiring radiation therapy. Additionally, after a mean clinical follow-up of 24.5 months, 4 patients (6.3%) demonstrated recurrent disease. Conclusions Direct endonasal transsphenoidal surgery enables safe and effective resection of large sellar masses while maintaining a favorable morbidity profile.