Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas

ABSTRACT

Introduction

Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas.

Areas covered

We discuss the evolution of the surgical practice from the use of the ‘microscope’ to the ‘endoscope’ in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019.

Expert opinion

Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.

KEYWORDS:

• Pituitary adenoma
• endoscopic endonasal approach
• complications
• hypopituitarism
• cerebrospinal fluid leak
• ICA injury

Article highlights

• Over the last two decades there has been a gradual shift from the traditional microscopic approach towards the use of endoscopic endonasal approach for resection of pituitary adenomas.

• Recent evidence suggests that experienced surgeons performing microscopic surgery and less experienced surgeons performing endoscopic surgery can achieve similar extents of tumor resection and quality outcomes in patients with nonfunctioning pituitary adenomas with potential for lower risk of postoperative pituitary gland dysfunction with the endoscopic techniques.

• There is some evidence that endoscopic-assisted surgery may be associated with better rates of pituitary gland preservation and function compared to the use of the microscope without compromising extent of resection.

• Endoscopic technique is also potentially better for achieving greater extent of resection in patients with significant parasellar extension and involvement of the cavernous sinus.

• ICA injury is a rare but dreaded complication. The risk of such injury can be reduced by meticulous surgical technique and good understanding of anatomico-technical nuances. Prompt access to interventional radiology services is paramount in the management of this complication.

• Close collaboration with the otolaryngologists and endocrinologists in high volume centers leads to better outcomes for the patients.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.