Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors. Part 2

OBJECTIVE: The widespread use of the endoscope in transsphenoidal pituitary surgery has recently contributed to the extension of the approach beyond the tuberculum sellae and planum sphenoidale for the management of lesions located in the suprasellar area, either with an endoscope-assisted or purely endoscopic technique. Based on our previous experience with more than 450 standard endoscopic transsphenoidal operations, we have retrospectively evaluated the effectiveness of the extended endoscopic endonasal transsphenoidal approach in the management of lesions mainly located in the suprasellar area. METHODS: Between January 2004 and December 2005, 20 consecutive patients underwent extended endoscopic endonasal transsphenoidal surgery for a total of 21 procedures. The series consisted of seven pituitary adenomas, seven craniopharyngiomas, three suprasellar Rathke’s cleft cysts, two tuberculum sellae meningiomas, and one pilocytic astrocytoma of the chiasm. RESULTS: Tumor removal, as assessed by postoperative magnetic resonance imaging, revealed complete removal of the lesion in four out of seven pituitary adenomas, five out of seven craniopharyngiomas, three out of three Rathke’s cleft cysts, and two out of two tuberculum sellae meningiomas. One patient (5%) with craniopharyngioma had a postoperative cerebrospinal fluid leak that required reoperation. The same patient experienced a sphenoid mycosis, which was treated with medical therapy. Some specific conditions associated with the anatomy of the surgical route, as well as to the morphology of the lesion, have resulted to condition the feasibility of the approach. CONCLUSION: Small and medium sized suprasellar lesions located in the midline, with or without a limited parasellar extension and without involvement of vascular structures, seem amenable to be resected through such extended endoscopic transsphenoidal approach. Improvements in closure techniques and the use of new materials and surgical glues seem to significantly reduce the postoperative cerebrospinal fluid leak rate and meningitis.