Literature ReviewEndoscopic Endonasal Versus Microscopic Transsphenoidal Surgery for Recurrent and/or Residual Pituitary Adenomas
Introduction
Transsphenoidal resection of a pituitary adenoma is one of the most commonly performed surgeries for intracranial tumors. Although the rate of gross total resection is high for small tumors, residual tumor following resection is not uncommon,1, 2, 3, 4 particularly for larger tumors, where gross total resection (GTR) rates can be as low as 25%–40%.5 Surgery for a recurrent or residual lesion is burdened by an increased risk of morbidity and mortality and more often results in incomplete resection compared with the primary surgery. Repeat transsphenoidal surgery is generally more difficult to perform than the initial operation.6, 7, 8, 9, 10 Distortion of surgical landmarks from prior surgery, formation of scar tissue, and the effects of preoperative radiotherapy or medical treatment may contribute to the difficulty encountered during surgery. The efficacy of the endoscopic endonasal approach for the management of pituitary tumors has been reported in the literature, with results and complications rates comparable or better than larger microsurgical series.11, 12, 13 The application of endoscopy to pituitary surgery is based on multiple theoretical advantages including improved visualization, preservation of sinonasal function, reduced hospital length of stay, increased patient comfort, and reduced complications.11 The visualization afforded by straight and angled endoscopes may enhance the identification of critical neurovascular structures and arachnoid violations of tumor, thereby improving the extent of resection and decreasing the rate of complications, particularly in reoperations. Despite its purported advantages, however, there is still a paucity of data on outcomes on endoscopic pituitary surgery when compared with the standard microscopic approach for recurrent or residual adenomas. In theory, the endoscopic approach would offer advantages such as the ability to visualize areas of residual tumor that might not be visible with the more limited field of view of the microscope. However, the frequent scarring tissue and more fibrotic surgical environment in redo surgeries can be challenging with the absence of direct stereoscopic visualization as proved by the microscope. The more challenging bimanual dissection through the endoscope, and the difficulty of skull base reconstruction in redo surgery might also limit the benefits or increase the complications of endoscopic approaches. Evaluation of the outcome and safety of these 2 approaches in recurrent/residual cases is even more pertinent in the light of the relative recent development of complementary adjuvant treatments such as radiosurgery.14, 15 In the present study, we analyzed the differences between endoscopic endonasal and microscopic transsphenoidal surgery for recurrent or residual pituitary adenomas by performing a systematic review and meta-analysis of the current literature, focusing on the preoperative tumor characteristics, extent of resection, visual outcome, endocrine remission, and complications.
Section snippets
Literature Search
A systematic review of the published literature to compare the outcomes between endoscopic endonasal and microscopic transsphenoidal surgery for recurrent or residual pituitary adenomas was performed using the Medline (via PubMed) database. Two independent researchers comprehensively reviewed English language studies from December 1985 to February 2015 and following PRISMA guidelines (Figure 1). Abstracts were then reviewed, followed by close inspection of acquired full-text articles. Finally,
Patients and Tumor Characteristics
From the total of 21 included articles, 8 studies7, 10, 16, 17, 18, 19, 20, 21 described endoscopic surgery results, with a total of 292 patients, while 13 studies22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 reported microscopic surgery outcomes totaling 684 patients. In the endoscopic group, 7 papers (201patients) reported the patients' gender with an aggregate female-to-male ratio of 1.36:1. In the microscopic group, the sex aggregate ratio was 2.28:1 over 8 articles (315 patients). The
Discussion
Recurrence of pituitary adenomas after both traditional microsurgical resection and endoscopic endonasal approaches is not uncommon.1, 2, 3, 4, 7 Risk factors for recurrence include incomplete resection at the time of initial surgery, invasion of the cavernous sinus, and tumor type.2, 3, 4, 24 This article demonstrates the current increasing use of endoscopic approaches for recurrent or residual adenomas, positively impacting the surgical outcomes and complications. However, some of the results
Conclusions
The use of the endoscopic endonasal approach is currently a widespread technique for approaching residual and recurrent pituitary adenomas. Because the endoscope and associated expanded approaches permit wider visualization, surgeons tend to tackle larger, more invasive adenomas with suprasellar and cavernous sinus extension. Our findings that extent of resection is only modestly increased may be more impactful, in light of this selection bias. Surgery on larger, more invasive tumors also
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Conflict of interest statement: This work was supported by a grant from the Clinical and Translational Science Center at Weill Cornell Medical College and funding from Dr. Paul J. Christos and Elizabeth Mauer, M.S. [UL1-TR000457-06]. No authors have any conflict of interest.
Yoshua Esquenazi and Walid I. Essayed contributed equally to the manuscript.