Original Article
Endonasal Endoscopic Pituitary Adenoma Resection: Preservation of Neurohypophyseal Function Vaclav Masopust1
David Netuka1
Vladimir Benes1
1 Department of Neurosurgery, 1st Faculty of Medicine, Charles
University and Central Military Hospital, Prague, Czech Republic 2 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
Ondrej Bradac1
Josef Marek2
Vaclav Hana2
Address for correspondence Vaclav Masopust, MD, Department of Neurosurgery, Central Military Hospital, U vojenské nemocnice 1200, Prague 16200, Czech Republic (e-mail: [email protected]).
J Neurol Surg A 2014;75:336–342.
Abstract
Keywords
► endoscopic endonasal resection ► pituitary adenoma ► diabetes insipidus ► postoperative frequency of diabetes insipidus
Objectives In the past 10 years, endoscopic resection of pituitary adenomas has become an alternative to microsurgical resection with the additional advantage of increasing the patient’s postoperative comfort. This analysis explored whether endoscopic resection can reduce the risk of postoperative neurohypophyseal dysfunction. Design We rated and compared the need to administer desmopressin during the first four postoperative days and with the need after a follow-up of at least 3 months (chronic administration). Setting Three groups of patients were compared: Patients in group 1 were operated on microscopically. Patients in group 2 were operated on endoscopically. Patients in group 3 were operated on endoscopically with intraoperative magnetic resonance imaging (iMRI). Participants Group 1 was made up of 50 patients treated in 1999; group 2 comprised 50 patients operated on from 2006 to 2007; and Group 3 comprised 50 patients operated on in 2008. Main Outcome Measures In group 1 the need to use desmopressin postoperatively occurred in eight patients; three needed chronic treatment. In group 2 the need for postoperative application of desmopressin occurred in four patients; none required chronic treatment. In group 3 desmopressin had to be administered postoperatively in five patients but only temporarily. Results and Conclusions Endoscopic surgery is a safe and effective method for the resection of pituitary adenomas. The rate of chronic desmopressin application was reduced. In conjunction with iMRI and navigation, the endoscopic technique allows increased radicality together with fewer adverse effects.
Introduction In 1910, Cushing performed his first transsphenoidal operation for pituitary adenoma using a sublabial incision.1,2 However, in 1925, he abandoned the transsphenoidal
received March 14, 2013 accepted after revision December 10, 2013 published online March 28, 2014
approach in favor of the transcranial route. Nevertheless, the sublabial transsphenoidal approach was not entirely disregarded, mainly thanks to Dott and Guiot. These surgeons introduced the use of intraoperative fluoroscopy. At about the same time, Hardy made a major breakthrough in pituitary
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1368687. ISSN 2193-6315.
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336
Endoscopic Pituitary Adenoma Resection
337
In our research we tried to determine whether the endoscopic technique with iMRI would increase not only radicality but also decrease morbidity.
Material and Methods We compared three groups of patients. Group 1 was made up of 50 patients (28 men and 22 women with a mean age of 56 years) treated from January 1999 to October 1999; group 2 comprised 50 patients (23 men and 27 women with a mean age of 50 years) operated on from May 2006 to February 2007; and group 3 comprised 50 patients (22 men and 28 women with a mean age of 57 years) operated on in 2008. Patients in group 1 were operated on microscopically using the sublabial technique. Patients in group 2 were operated on endoscopically using the direct transnasal technique. Patients in group 3 were operated on endoscopically in conjunction with iMRI. In group 1, there were 21 micro- and 29 macroadenomas; of these, 23 were hormonally active and 27 hormonally inactive (requiring surgery for visual disorder or for compression of surrounding structures). In group 2, there were 15 cases of micro- and 35 cases of macroadenoma, with 19 hormonally active and 31 hormonally inactive. The patients in group 3 underwent surgery for 6 micro- and 44 macroadenomas (12 were hormonally active and 38 hormonally inactive). The first endoscopic operations were performed using the mononostril technique7–11. The middle nasal turbinate is lateralized first to help open the sphenoid cavity by way of the ipsilateral sphenoid ostium. Only the contralateral part inside the sphenoid cavity is properly opened. In a single nostril it is possible to introduce the endoscope and one other
Fig. 1 Operating room with intraoperative magnetic resonance imaging.
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neurosurgery with his use of the microscope, which opened the way to a widespread resurrection of the sublabial approach.3 The first transsphenoidal operation of the pituitary at the Central Military Hospital in Prague was performed by Černý in 1972. Later, the approach was mainly studied by Fusek, who started using this approach in the 1970s.4–6 The promotion of this approach, however, was a slow, steady process rather than a huge leap. In 1977, the ratio between transcranial and transsphenoidal approaches at the Central Military Hospital was 1.5:1, and it was 1:6 in 2003. At present, endoscopy is the main method of surgery for pituitary adenoma in our department. Until the beginning of 2004, the sublabial transseptal approach had been used at our center. From April 2004 to April 2006, however, we preferred the direct endonasal route using the microscope. In May 2006, we included the endoscopic mononostril endonasal approach in our armamentarium. Since November 2006, we have been taking advantage of the binostril endoscopic endonasal technique. Since April 2008, surgical operations have been taking place in the intraoperative magnetic resonance imaging (iMRI) suite (►Fig. 1). The four therapeutic approaches to sellar lesions are observation, neurosurgery, treatment with medication, and radiosurgery (mostly using gamma knife in our country). Rather than being mutually exclusive, these modalities are complementary. Clearly, modern surgical techniques have led to increased radicality and fewer undesirable side effects. However, this does not imply that the other methods should be abandoned. No surgery of this type would be feasible without a comprehensive range of endocrinologic services.
Masopust et al.
Endoscopic Pituitary Adenoma Resection
Masopust et al. In our cohort, we rated and compared the need to administer desmopressin during the first 4 postoperative days. Rather than looking for differences in the dosage of desmopressin, we ensured that the drug was administered at least once daily in the postoperative period for a minimum of two consecutive days. A 1-day administration of desmopressin on the day of surgery without the need for further administration was not rated as a postoperative pituitary deficit. If desmopressin was needed after a follow-up of at least 3 months, a chronic need was assumed. Regarding ethical considerations, all screening methods cited in this article are a prevalent part of medical standards in our country.
instrument. Placed in the same nostril, the endoscope limits the movement of the bayonet instruments that normally need greater operative space. Considering the instrument’s fine movements, the assistant’s inadvertent movements with the endoscope could cause accidental movement of the instrument in the sella turcica, potentially resulting in a very dangerous situation.We gradually adopted the binostral technique (the “four-hand technique”),12–16 which means that septum lateralization is not required. We resect only a small area ( 0.5 0.5 cm) in the posterior part of the nasal septum. In most cases we ablate the middle concha. The use of both nostrils offers several advantages including more working space and a greater range of instrument movement. For most of the surgery time, only one instrument, one drain cannula, and the endoscope are used. At a certain point of any operation, two instruments have to be used at the same time: drain cannula and endoscope (the four-hand technique). At present, our operations take place in a multifunction room, where data transmitted from an intraoperative 3-TMR system (General Electric, USA) are updated in the navigation system (Brainlab, Germany). Since the late 1990s, an increasing number of publications have described endoscopic techniques of surgery for sellar lesions. In May 2006, we made the endoscopic mononostril endonasal approach an essential part of our armamentarium. Since November 2006, we have been using the binostril endoscopic endonasal approach with the aid of Storz 0and 30-degree (Karl Storz Endoscope, Germany) and Wolf 0-degree (Richard Wolf, GmbH, Germany) endoscopes. In our practice, desmopressin is used in the postoperative period in cases in which urine specific gravity is reduced to < 1004 and the patient’s negative balance exceeds 500 mL per 12 hours. Checks are continually made to determine blood sodium level, which must not be allowed to drop below 132 mmol/L. The same applies to checking on any hypernatremia for pure water loss.
In group 1, eight patients (in three patients, use was chronic) required postoperative treatment with desmopressin, Minirin Spray (Ferring-Léčiva, Jesenice, Czech Republic); later on Minirin-Melt (Ferring Pharmaceuticals, New York, United States) was used. In group 2, four patients required desmopressin postoperatively, but none chronically used desmopressin. In group 3, only five patients temporarily required postoperative treatment with desmopressin. Results are summarized in ►Fig. 5. MRI radical resection was achieved in 48% of cases in group 1, in 50% in group 2, and in 72% in group 3. ►Figs. 2, 3 and 4 summarize the use of preoperative, intraoperative, and postoperative MRI in the case of MRI radical resection. In group 1, hormone normalization was achieved in 14 (60.8%) of 23 hormonally active adenomas. In group 2, hormone normalization was achieved in 12 (63.1%) of 19 hormonally active adenomas. In group 3, hormone normalization was achieved in 8 (66.6%) of 12 hormonally active adenomas. New postoperative endocrine deterioration (thyroid, adrenocorticotropic, or gonadotropic axis) that necessitated longtime substitution therapy was observed in 10 patients in
Fig. 2 Preoperative magnetic resonance image of pituitary adenoma.
Fig. 3 Intraoperative image of residual adenoma.
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Results
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Endoscopic Pituitary Adenoma Resection
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Comparison to the extent of resection is summarized in ►Fig. 6.
Fig. 4 Postoperative magnetic resonance image after radical resection.
group 1, 4 in group 2, and 3 in group 3. Postoperative epistaxis was observed in three cases in group 1 and one case both in group 2 and 3. Concerning the other neurologic complications in group 1, bilateral loss of vision occurred in one patient 2 hours postsurgery. Emergency revision for rebleed into the resection cavity resulted in complete restoration of vision on one eye and partial restoration on the other. In group 2, there was one case of gradual postoperative deterioration of vision without evidence of pressure on the chiasm at the MR control. We assumed that a vascular lesion due to long-term preoperative massive compression of the chiasm caused the complication. No neurologic complications were noted in group 3. Cerebrospinal fluid (CSF) leakage occurred in three patients in group 3 (requiring revision in one patient) and in eight patients in group 2 (three of whom needed revision).
In 2004, we abandoned the classic sublabial transseptal approach in favor of the direct endonasal route. From April 2004 to April 2006, we used the microscope-aided direct endonasal approach. Microsurgical techniques (in both the sublabial and direct endonasal approach) require the use of an endonasal dilator, an instrument compressing the adjacent nasal mucosa. This compression can lead to ischemia and subsequent synechia. Closing any communication with the CSF spaces is the salient part of the resection. At first, the number of such communications increased with the growing radicality of the operation: the greater the radicality, the greater the risk of diaphragmatic damage, and subsequently, that of postoperative CSF leakage. In the new series, different techniques of CSF space sealing were used, both classical ones17,18 (using fascia, muscle or fat, and tissue adhesive [TachoSil, Nycomed, Switzerland]) and artificial material (DuraForm, Johnson & Johnson, USA). With the respective technique adopted, the number of cases of CSF leakage is again on the decline. The risk of postoperative CSF leakage in group 2 of our cohort dropped from the initial 10% to 5%. Far from regarding microsurgical techniques as obsolete, growing evidence indicates that endoscopic surgery attains superior results. Some neurosurgical centers abroad, however, continue to recommend microsurgery.19–22 Admittedly, for neurosurgeons familiar with operating under the microscope, the transition to endoscopic techniques is an intricate and therefore potentially risky procedure.23 A considerable advantage also lies in the use of new technologies designed to help manage the resection of even a fairly solid mass (e.g., ultrasonic aspirator), although these technologies need more access space. The new techniques allow safely differentiating between the pituitary and the tumor thus minimizing damage to neurohypophyseal
Fig. 5 Comparison of radical surgery and the use of desmopressin in microscopic operations, at the start of endoscopic operations, and endoscopic operation together with intraoperative 3-T magnetic resonance (MR) imaging.
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Discussion
Endoscopic Pituitary Adenoma Resection
Masopust et al.
Fig. 6 Comparison between radical surgery and the occurrence of cerebrospinal fluid (CSF) leakage in microscopic surgery, at the start of endoscopic surgery and in endoscopic surgery together with intraoperative 3-T magnetic resonance (MR) imaging.
functions and increasing radicality.24 They also reduce the need for pulling of the tumor, and consequently, of the pituitary stalk, which might explain the reduced need for chronic treatment with desmopressin. However, it is questionable whether this would be the case in microadenomas. In tiny hormonally active neoplasms, it helps navigating directly to the tumor, reducing the risk of adenohypophyseal damage, and consequently increasing the chance for complete preservation of pituitary functions.25 Using iMRI, we can continuously evaluate the actual situation and remove minor residual parts of the tumor around the sinus and the carotid as much as around the chiasma. Thus radicality in group 3 was increased compared with the condition of using no iMRI. Very similar results were reported by Nimsky et al (i.e., a 40% increase in radicality in adenomas where radicality was expected beforehand)26 and other authors.27–33 Radicality is of major importance in assessing a surgical procedure as is the need to reduce hormone excess. In our view, considering the existence of multiple, potentially interconnected therapeutic modalities, the primary objective is that of surgical risk reduction. Today, the risk of surgery is already quite low (up to 2%). Antidiuretic hormone (ADH) is a protein. Its function is to control the reabsorption with the aid of the aquaporin 2 channel in the collecting tubule membrane and thus to control ion and water balance in the body. ADH is produced
in the hypothalamus (mostly in the supraoptic nucleus) and conveyed along axons in the pituitary stalk into the posterior pituitary (neurohypophysis) where it is stored and subsequently released into the blood circulation as needed. Because the axons in the pituitary stalk are relatively vulnerable, the frequency of their damage, in our view, is ideal for assessing different techniques of adenoma resection which have avoidance of undue manipulation of the neurohypophysis and the stalk in common. Short-term desmopressin need may not be considered a serious complication of surgery. However, chronic application hampers patient’s quality of life. As our study shows, the rate of postoperative administration of desmopressin was curtailed with the use of the endoscopic endonasal technique in patients undergoing pituitary adenoma resection (►Tables 1 and 2). Similar results were obtained despite increased radicality using iMRI. This result is especially favorable, because the number of macroadenomas in group 3 was higher than that of microadenomas (►Table 3). It would not be fair to claim that a reduced number of side effects of sellar tumor resection has been achieved solely by technological progress in terms of instruments, navigation, or iMRI. The factor of time has had a significant role, as has the growing experience of the operating team.25,34 From this point of view, concentration of pituitary surgery in well-equipped and high-volume centers seems to be the right future direction.
Table 1 Comparison of the use of desmopressin after microscopic and endoscopic operations
Table 2 Comparison of the chronic use of desmopressin after microscopic and endoscopic operations
Early desmopressin administration
Chronic desmopressin administration
No
Yes
Microscopy
42
8
Endoscopy
91
9
p ¼ 0.274; Fisher test. Journal of Neurological Surgery—Part A
No
Yes
Microscopy
47
3
Endoscopy
100
0
p ¼ 0.036; Fisher test. Vol. 75
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340
Endoscopic Pituitary Adenoma Resection the
numbers
of
micro-
and
Adenoma types across groups Micro
Macro
Group 1 (microscope)
21
29
Group 2 (endoscope)
15
35
Group 3 (endoscope þ iMRI)
6
44
10 de Divitiis E, Cappabianca P. Endoscopic endonasal transsphenoi-
11
12
13
Abbreviation: iMRI, intraoperative magnetic resonance imaging. p ¼ 0.035; chi-square test. 14
New technologies do not just have benefits. Without previous experience, increased radicality achieved by iMRI can be at expense of more side effects. However, thanks to the gradual expansion of our armamentarium and experience, no such adverse events have occurred.
Conclusion Endoscopic techniques offer more comfort to the patient. They have been proven to shorten patients’ postoperative hospitalization time, as well as relieve them of the uncomfortable tamponade of the nasal cavity. A reduced need for chronic desmopressin therapy documents the higher selectivity of endoscopic endonasal surgery for the resection of pituitary adenoma.
15
16
17
18
19 20
Acknowledgments The study was supported by IGA MZ NT 13631, 14256, and PRVOUK-P25/LF1/7.
21
22 23
References 1 Rosegay H. Cushing’s legacy to transsphenoidal surgery. J Neuro-
surg 1981;54(4):448–454
24
2 Walker EA. A History of Neurological Surgery. Baltimore, MD:
Williams and Wilkins; 1982 3 Hardy J. Transsphenoidal hypophysectomy. J Neurosurg 1971;
34(4):582–594 4 Fusek I, Černý E. Transsphenoidal operation of hypophyseal tu5
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mors. J Neurosurg Sci 1977;21:2–3, 159–160 Fusek I, Černý E. Our experience of indications for transsphenoidal surgery on Turkish saddle tumours [in Czech]. Česka A Slovenska Neurol Neurochir 1978;41/74(2):107–114 Fusek I. Surgical Treatment for Turkish Saddle Tumours Using the Transsphenoidal Approach [in Czech]. Prague, Czech Republic: Avicenum Czechoslovak Medical Press; 1986 Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 1998; 41(2):66–73 Cappabianca P, Alfiery A, de Divitiis E, et al. Atlas of Endoscopic Anatomy for Endonasal Intracranial Surgery. New York, NY: Springer-Verlag; 2001:134 Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E. Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery 1999;45(2):392–395; discussion 395–396
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dal surgery. In Pickard JD, ed. Advances and Technical Standards in Neurosurgery. Vol 27. New York, NY: Springer Verlag; 2002: 137–177 de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 2002;51:669–707 Das K, Spencer W, Nwagwu CI, et al. Approaches to the sellar and parasellar region: anatomic comparison of endonasal-transsphenoidal, sublabial-transsphenoidal, and transethmoidal approaches. Neurol Res 2001;23(1):51–54 Derome PJ. The transbasal approach to tumors invading the skull base. In Schmidek HH, Sweet WH, eds. Operative Neurosurgical Techniques: Indications, Methods and Results. Vol 1. New York, NY: Grune and Stratton; 1998:619–633 Hashimoto N, Kikuchi H. Transsphenoidal approach to infrasellar tumors involving the cavernous sinus. J Neurosurg 1990;73(4): 513–517 Kitano M, Taneda M. Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note. J Neurosurg 2001;94(6):999–1004 Lalwani AK, Kaplan MJ, Gutin PH. The transsphenoethmoid approach to the sphenoid sinus and clivus. Neurosurgery 1992; 31(6):1008–1014; discussion 1014 Munich SA, Fenstermaker RA, Fabiano AJ, Rigual NR. Cranial base repair with combined vascularized nasal septal flap and autologous tissue graft following expanded endonasal endoscopic neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2013;74(2): 101–108 Malik MU, Aberle JC, Flitsch J. CSF fistulas after transsphenoidal pituitary surgery—a solved problem? J Neurol Surg A Cent Eur Neurosurg 2012;73(5):275–280 Ray BS. Intracranial hypophysectomy. J Neurosurg 1968;28(2): 180–186 Ray BS, Patterson RH Jr. Surgical treatment of pituitary adenomas. J Neurosurg 1962;19:1–8 Yasargil MG. Microneurosurgery. Microsurgical Anatomy of the Basal Cisterns and Vessels of the Brain. Vol 1. Stuttgart, Germany: Thieme; 1984:208–244 Yasargil MG. Complication in Aneurysm Surgery in Microneurosurgery. Vol 2. New York, NY: Thieme; 1984:331–339 Cappabianca P, Briganti F, Cavallo LM, de Divitiis E. Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach. Acta Neurochir (Wien) 2001;143(1):95–96 Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD, de Divitiis E. Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 2001;49(2): 473–475; discussion 475–476 Netuka D, Masopust V, Belšán T, Kramář F, Beneš V. Initial experience of the use of intraoperative MR in pituitary adenoma resections. Česka A Slovenska Neurologie Neurochirurgie 2009; 105(1):45–50 Nimsky C, Ganslandt O, Von Keller B, Romstöck J, Fahlbusch R. Intraoperative high-field-strength MR imaging: implementation and experience in 200 patients. Radiology 2004;233(1):67–78 Elias WJ, Chadduck JB, Alden TD, Laws ER Jr. Frameless stereotaxy for transsphenoidal surgery. Neurosurgery 1999;45(2):271–275; discussion 275–277 Fahlbusch R, Keller BV, Ganslandt O, Kreutzer J, Nimsky C. Transsphenoidal surgery in acromegaly investigated by intraoperative high-field magnetic resonance imaging. Eur J Endocrinol 2005; 153(2):239–248 Nimsky C, von Keller B, Ganslandt O, Fahlbusch R. Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 2006;59(1):105–114; discussion 105–114 Journal of Neurological Surgery—Part A
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Table 3 Comparison of macroadenomas in groups
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30 Jones J, Ruge J. Intraoperative magnetic resonance imaging in
pituitary macroadenoma surgery: an assessment of visual outcome. Neurosurg Focus 2007;23(5):E12 31 Schwartz TH, Stieg PE, Anand VK. Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 2006;58(1, Suppl):ONS44–ONS51; discussion ONS44–ONS51 32 Bohinski RJ, Warnick RE, Gaskill-Shipley MF, et al. Intraoperative magnetic resonance imaging to determine the extent of resection
of pituitary macroadenomas during transsphenoidal microsurgery. Neurosurgery 2001;49(5):1133–1143; discussion 1143– 1144 33 Alfieri A, Jho HD. Endoscopic endonasal cavernous sinus surgery: an anatomic study. Neurosurgery 2001;48(4):827–836; discussion 836–837 34 Masopust V, Netuka D, Beneš V. Endonasal endoscopic transsphenoidal resection of sellar lesions. Česka A Slovenska Neurol Neurochir 2008;104(6):704–710
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Endonasal Endoscopic Pituitary Adenoma Resection: Preservation of Neurohypophyseal Function Vaclav Masopust1
David Netuka1
Vladimir Benes1
1 Department of Neurosurgery, 1st Faculty of Medicine, Charles
University and Central Military Hospital, Prague, Czech Republic 2 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
Ondrej Bradac1
Josef Marek2
Vaclav Hana2
Address for correspondence Vaclav Masopust, MD, Department of Neurosurgery, Central Military Hospital, U vojenské nemocnice 1200, Prague 16200, Czech Republic (e-mail: [email protected]).
J Neurol Surg A 2014;75:336–342.
Abstract
Keywords
► endoscopic endonasal resection ► pituitary adenoma ► diabetes insipidus ► postoperative frequency of diabetes insipidus
Objectives In the past 10 years, endoscopic resection of pituitary adenomas has become an alternative to microsurgical resection with the additional advantage of increasing the patient’s postoperative comfort. This analysis explored whether endoscopic resection can reduce the risk of postoperative neurohypophyseal dysfunction. Design We rated and compared the need to administer desmopressin during the first four postoperative days and with the need after a follow-up of at least 3 months (chronic administration). Setting Three groups of patients were compared: Patients in group 1 were operated on microscopically. Patients in group 2 were operated on endoscopically. Patients in group 3 were operated on endoscopically with intraoperative magnetic resonance imaging (iMRI). Participants Group 1 was made up of 50 patients treated in 1999; group 2 comprised 50 patients operated on from 2006 to 2007; and Group 3 comprised 50 patients operated on in 2008. Main Outcome Measures In group 1 the need to use desmopressin postoperatively occurred in eight patients; three needed chronic treatment. In group 2 the need for postoperative application of desmopressin occurred in four patients; none required chronic treatment. In group 3 desmopressin had to be administered postoperatively in five patients but only temporarily. Results and Conclusions Endoscopic surgery is a safe and effective method for the resection of pituitary adenomas. The rate of chronic desmopressin application was reduced. In conjunction with iMRI and navigation, the endoscopic technique allows increased radicality together with fewer adverse effects.
Introduction In 1910, Cushing performed his first transsphenoidal operation for pituitary adenoma using a sublabial incision.1,2 However, in 1925, he abandoned the transsphenoidal
received March 14, 2013 accepted after revision December 10, 2013 published online March 28, 2014
approach in favor of the transcranial route. Nevertheless, the sublabial transsphenoidal approach was not entirely disregarded, mainly thanks to Dott and Guiot. These surgeons introduced the use of intraoperative fluoroscopy. At about the same time, Hardy made a major breakthrough in pituitary
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1368687. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
336
Endoscopic Pituitary Adenoma Resection
337
In our research we tried to determine whether the endoscopic technique with iMRI would increase not only radicality but also decrease morbidity.
Material and Methods We compared three groups of patients. Group 1 was made up of 50 patients (28 men and 22 women with a mean age of 56 years) treated from January 1999 to October 1999; group 2 comprised 50 patients (23 men and 27 women with a mean age of 50 years) operated on from May 2006 to February 2007; and group 3 comprised 50 patients (22 men and 28 women with a mean age of 57 years) operated on in 2008. Patients in group 1 were operated on microscopically using the sublabial technique. Patients in group 2 were operated on endoscopically using the direct transnasal technique. Patients in group 3 were operated on endoscopically in conjunction with iMRI. In group 1, there were 21 micro- and 29 macroadenomas; of these, 23 were hormonally active and 27 hormonally inactive (requiring surgery for visual disorder or for compression of surrounding structures). In group 2, there were 15 cases of micro- and 35 cases of macroadenoma, with 19 hormonally active and 31 hormonally inactive. The patients in group 3 underwent surgery for 6 micro- and 44 macroadenomas (12 were hormonally active and 38 hormonally inactive). The first endoscopic operations were performed using the mononostril technique7–11. The middle nasal turbinate is lateralized first to help open the sphenoid cavity by way of the ipsilateral sphenoid ostium. Only the contralateral part inside the sphenoid cavity is properly opened. In a single nostril it is possible to introduce the endoscope and one other
Fig. 1 Operating room with intraoperative magnetic resonance imaging.
Journal of Neurological Surgery—Part A
Vol. 75
No. A5/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
neurosurgery with his use of the microscope, which opened the way to a widespread resurrection of the sublabial approach.3 The first transsphenoidal operation of the pituitary at the Central Military Hospital in Prague was performed by Černý in 1972. Later, the approach was mainly studied by Fusek, who started using this approach in the 1970s.4–6 The promotion of this approach, however, was a slow, steady process rather than a huge leap. In 1977, the ratio between transcranial and transsphenoidal approaches at the Central Military Hospital was 1.5:1, and it was 1:6 in 2003. At present, endoscopy is the main method of surgery for pituitary adenoma in our department. Until the beginning of 2004, the sublabial transseptal approach had been used at our center. From April 2004 to April 2006, however, we preferred the direct endonasal route using the microscope. In May 2006, we included the endoscopic mononostril endonasal approach in our armamentarium. Since November 2006, we have been taking advantage of the binostril endoscopic endonasal technique. Since April 2008, surgical operations have been taking place in the intraoperative magnetic resonance imaging (iMRI) suite (►Fig. 1). The four therapeutic approaches to sellar lesions are observation, neurosurgery, treatment with medication, and radiosurgery (mostly using gamma knife in our country). Rather than being mutually exclusive, these modalities are complementary. Clearly, modern surgical techniques have led to increased radicality and fewer undesirable side effects. However, this does not imply that the other methods should be abandoned. No surgery of this type would be feasible without a comprehensive range of endocrinologic services.
Masopust et al.
Endoscopic Pituitary Adenoma Resection
Masopust et al. In our cohort, we rated and compared the need to administer desmopressin during the first 4 postoperative days. Rather than looking for differences in the dosage of desmopressin, we ensured that the drug was administered at least once daily in the postoperative period for a minimum of two consecutive days. A 1-day administration of desmopressin on the day of surgery without the need for further administration was not rated as a postoperative pituitary deficit. If desmopressin was needed after a follow-up of at least 3 months, a chronic need was assumed. Regarding ethical considerations, all screening methods cited in this article are a prevalent part of medical standards in our country.
instrument. Placed in the same nostril, the endoscope limits the movement of the bayonet instruments that normally need greater operative space. Considering the instrument’s fine movements, the assistant’s inadvertent movements with the endoscope could cause accidental movement of the instrument in the sella turcica, potentially resulting in a very dangerous situation.We gradually adopted the binostral technique (the “four-hand technique”),12–16 which means that septum lateralization is not required. We resect only a small area ( 0.5 0.5 cm) in the posterior part of the nasal septum. In most cases we ablate the middle concha. The use of both nostrils offers several advantages including more working space and a greater range of instrument movement. For most of the surgery time, only one instrument, one drain cannula, and the endoscope are used. At a certain point of any operation, two instruments have to be used at the same time: drain cannula and endoscope (the four-hand technique). At present, our operations take place in a multifunction room, where data transmitted from an intraoperative 3-TMR system (General Electric, USA) are updated in the navigation system (Brainlab, Germany). Since the late 1990s, an increasing number of publications have described endoscopic techniques of surgery for sellar lesions. In May 2006, we made the endoscopic mononostril endonasal approach an essential part of our armamentarium. Since November 2006, we have been using the binostril endoscopic endonasal approach with the aid of Storz 0and 30-degree (Karl Storz Endoscope, Germany) and Wolf 0-degree (Richard Wolf, GmbH, Germany) endoscopes. In our practice, desmopressin is used in the postoperative period in cases in which urine specific gravity is reduced to < 1004 and the patient’s negative balance exceeds 500 mL per 12 hours. Checks are continually made to determine blood sodium level, which must not be allowed to drop below 132 mmol/L. The same applies to checking on any hypernatremia for pure water loss.
In group 1, eight patients (in three patients, use was chronic) required postoperative treatment with desmopressin, Minirin Spray (Ferring-Léčiva, Jesenice, Czech Republic); later on Minirin-Melt (Ferring Pharmaceuticals, New York, United States) was used. In group 2, four patients required desmopressin postoperatively, but none chronically used desmopressin. In group 3, only five patients temporarily required postoperative treatment with desmopressin. Results are summarized in ►Fig. 5. MRI radical resection was achieved in 48% of cases in group 1, in 50% in group 2, and in 72% in group 3. ►Figs. 2, 3 and 4 summarize the use of preoperative, intraoperative, and postoperative MRI in the case of MRI radical resection. In group 1, hormone normalization was achieved in 14 (60.8%) of 23 hormonally active adenomas. In group 2, hormone normalization was achieved in 12 (63.1%) of 19 hormonally active adenomas. In group 3, hormone normalization was achieved in 8 (66.6%) of 12 hormonally active adenomas. New postoperative endocrine deterioration (thyroid, adrenocorticotropic, or gonadotropic axis) that necessitated longtime substitution therapy was observed in 10 patients in
Fig. 2 Preoperative magnetic resonance image of pituitary adenoma.
Fig. 3 Intraoperative image of residual adenoma.
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Results
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Comparison to the extent of resection is summarized in ►Fig. 6.
Fig. 4 Postoperative magnetic resonance image after radical resection.
group 1, 4 in group 2, and 3 in group 3. Postoperative epistaxis was observed in three cases in group 1 and one case both in group 2 and 3. Concerning the other neurologic complications in group 1, bilateral loss of vision occurred in one patient 2 hours postsurgery. Emergency revision for rebleed into the resection cavity resulted in complete restoration of vision on one eye and partial restoration on the other. In group 2, there was one case of gradual postoperative deterioration of vision without evidence of pressure on the chiasm at the MR control. We assumed that a vascular lesion due to long-term preoperative massive compression of the chiasm caused the complication. No neurologic complications were noted in group 3. Cerebrospinal fluid (CSF) leakage occurred in three patients in group 3 (requiring revision in one patient) and in eight patients in group 2 (three of whom needed revision).
In 2004, we abandoned the classic sublabial transseptal approach in favor of the direct endonasal route. From April 2004 to April 2006, we used the microscope-aided direct endonasal approach. Microsurgical techniques (in both the sublabial and direct endonasal approach) require the use of an endonasal dilator, an instrument compressing the adjacent nasal mucosa. This compression can lead to ischemia and subsequent synechia. Closing any communication with the CSF spaces is the salient part of the resection. At first, the number of such communications increased with the growing radicality of the operation: the greater the radicality, the greater the risk of diaphragmatic damage, and subsequently, that of postoperative CSF leakage. In the new series, different techniques of CSF space sealing were used, both classical ones17,18 (using fascia, muscle or fat, and tissue adhesive [TachoSil, Nycomed, Switzerland]) and artificial material (DuraForm, Johnson & Johnson, USA). With the respective technique adopted, the number of cases of CSF leakage is again on the decline. The risk of postoperative CSF leakage in group 2 of our cohort dropped from the initial 10% to 5%. Far from regarding microsurgical techniques as obsolete, growing evidence indicates that endoscopic surgery attains superior results. Some neurosurgical centers abroad, however, continue to recommend microsurgery.19–22 Admittedly, for neurosurgeons familiar with operating under the microscope, the transition to endoscopic techniques is an intricate and therefore potentially risky procedure.23 A considerable advantage also lies in the use of new technologies designed to help manage the resection of even a fairly solid mass (e.g., ultrasonic aspirator), although these technologies need more access space. The new techniques allow safely differentiating between the pituitary and the tumor thus minimizing damage to neurohypophyseal
Fig. 5 Comparison of radical surgery and the use of desmopressin in microscopic operations, at the start of endoscopic operations, and endoscopic operation together with intraoperative 3-T magnetic resonance (MR) imaging.
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Discussion
Endoscopic Pituitary Adenoma Resection
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Fig. 6 Comparison between radical surgery and the occurrence of cerebrospinal fluid (CSF) leakage in microscopic surgery, at the start of endoscopic surgery and in endoscopic surgery together with intraoperative 3-T magnetic resonance (MR) imaging.
functions and increasing radicality.24 They also reduce the need for pulling of the tumor, and consequently, of the pituitary stalk, which might explain the reduced need for chronic treatment with desmopressin. However, it is questionable whether this would be the case in microadenomas. In tiny hormonally active neoplasms, it helps navigating directly to the tumor, reducing the risk of adenohypophyseal damage, and consequently increasing the chance for complete preservation of pituitary functions.25 Using iMRI, we can continuously evaluate the actual situation and remove minor residual parts of the tumor around the sinus and the carotid as much as around the chiasma. Thus radicality in group 3 was increased compared with the condition of using no iMRI. Very similar results were reported by Nimsky et al (i.e., a 40% increase in radicality in adenomas where radicality was expected beforehand)26 and other authors.27–33 Radicality is of major importance in assessing a surgical procedure as is the need to reduce hormone excess. In our view, considering the existence of multiple, potentially interconnected therapeutic modalities, the primary objective is that of surgical risk reduction. Today, the risk of surgery is already quite low (up to 2%). Antidiuretic hormone (ADH) is a protein. Its function is to control the reabsorption with the aid of the aquaporin 2 channel in the collecting tubule membrane and thus to control ion and water balance in the body. ADH is produced
in the hypothalamus (mostly in the supraoptic nucleus) and conveyed along axons in the pituitary stalk into the posterior pituitary (neurohypophysis) where it is stored and subsequently released into the blood circulation as needed. Because the axons in the pituitary stalk are relatively vulnerable, the frequency of their damage, in our view, is ideal for assessing different techniques of adenoma resection which have avoidance of undue manipulation of the neurohypophysis and the stalk in common. Short-term desmopressin need may not be considered a serious complication of surgery. However, chronic application hampers patient’s quality of life. As our study shows, the rate of postoperative administration of desmopressin was curtailed with the use of the endoscopic endonasal technique in patients undergoing pituitary adenoma resection (►Tables 1 and 2). Similar results were obtained despite increased radicality using iMRI. This result is especially favorable, because the number of macroadenomas in group 3 was higher than that of microadenomas (►Table 3). It would not be fair to claim that a reduced number of side effects of sellar tumor resection has been achieved solely by technological progress in terms of instruments, navigation, or iMRI. The factor of time has had a significant role, as has the growing experience of the operating team.25,34 From this point of view, concentration of pituitary surgery in well-equipped and high-volume centers seems to be the right future direction.
Table 1 Comparison of the use of desmopressin after microscopic and endoscopic operations
Table 2 Comparison of the chronic use of desmopressin after microscopic and endoscopic operations
Early desmopressin administration
Chronic desmopressin administration
No
Yes
Microscopy
42
8
Endoscopy
91
9
p ¼ 0.274; Fisher test. Journal of Neurological Surgery—Part A
No
Yes
Microscopy
47
3
Endoscopy
100
0
p ¼ 0.036; Fisher test. Vol. 75
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340
Endoscopic Pituitary Adenoma Resection the
numbers
of
micro-
and
Adenoma types across groups Micro
Macro
Group 1 (microscope)
21
29
Group 2 (endoscope)
15
35
Group 3 (endoscope þ iMRI)
6
44
10 de Divitiis E, Cappabianca P. Endoscopic endonasal transsphenoi-
11
12
13
Abbreviation: iMRI, intraoperative magnetic resonance imaging. p ¼ 0.035; chi-square test. 14
New technologies do not just have benefits. Without previous experience, increased radicality achieved by iMRI can be at expense of more side effects. However, thanks to the gradual expansion of our armamentarium and experience, no such adverse events have occurred.
Conclusion Endoscopic techniques offer more comfort to the patient. They have been proven to shorten patients’ postoperative hospitalization time, as well as relieve them of the uncomfortable tamponade of the nasal cavity. A reduced need for chronic desmopressin therapy documents the higher selectivity of endoscopic endonasal surgery for the resection of pituitary adenoma.
15
16
17
18
19 20
Acknowledgments The study was supported by IGA MZ NT 13631, 14256, and PRVOUK-P25/LF1/7.
21
22 23
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Table 3 Comparison of macroadenomas in groups
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