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Original article
peer-reviewed

Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures



Abstract

Introduction

Endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA) has been a recent shift from the traditional microscopic technique. Although some literature demonstrated superiority of ETSS over the microscopic method and some evaluated mono- vs. binostril access within the ETSS, none had explored the potential influence of dedicated instrument, as this procedure had evolved, on patients’ outcomes when compared to traditional microscopic tools.

Objective

To investigate our own clinical and radiographic outcomes of ETSS for PA with its technical evolution over time as well as a significance of, having vs. lacking, the special endoscopic tools.

Methods

Included patients underwent ETSS for PA performed by the first author (AH). Prospectively recorded patients’ data concerning pre-, intra- and postoperative clinical and radiographic assessments were subject to analysis. The three groups of differently evolving ETSS techniques, beginning with mononostril (MN) to binostril ETSS with standard microsurgical instruments (BN1) and, lastly, binostril ETSS with specially-designed endoscopic tools (BN2), were examined for their impact on the intra- and, short- and long-term, postoperative results. Also, the survival after ETSS for PA, as defined by the need for reintervention in each technical group, was appraised.

Results

From January 2006 to 2012, there were 47, 101 and 72 ETSS, from 183 patients, in the MN, BN1 and BN2 cohorts, respectively. Significant preoperative findings were greater proportion of patients with prior surgery (p=0.01) and tumors with parasellar extension (p=0.02) in the binostril (BN1&2) than the MN group. Substantially shorter operative time and less amount of blood loss were evident as our technique had evolved (p<0.001). Despite higher incidence, and more advanced grades, of cerebrospinal fluid leakage in the binostril groups (p < 0.001), the requirement for post-ETSS surgical repair was less than the mononostril cohort (p=0.04). At six-month follow-up (n=214), quantitative radiographic outcome analysis was markedly superior in BN2. Consequently, long-term result was better in this latest technical group. Important negative risk factors, from multivariate Cox regression analysis, were prior surgery, Knosp grade, and firm tumor while BN1, BN2 and percentages of anteroposterior dimension PA removal had positive effect on longer survival.

Conclusion

The evolution of technique for ETSS for PA from MN to BN2 has shown its efficacy by improving intra- and postoperative outcomes in our study cohorts. Based on our results, not only that a neurosurgeon, wishing to start performing ETSS, should enroll in a formal fellowship training but he/she should also utilize advanced endoscopic tools, as we have proved its superior results in dealing with PA. 



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Original article
peer-reviewed

Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures


Author Information

Ake Hansasuta

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Siriwut Pokanan

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Pritsana Punyawai

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Wattana Mahattanakul Corresponding Author

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Faculty of Medicine Ramathibodi Hospital, Mahidol University ethic review committee clearance issued approval ID 10-55-34. With approval from the institutional review committee, retrospective analysis of the ETSS records was conducted. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Acknowledgements

The authors would like to express our sincere gratitude for major assistance in statistical analysis along with valuable advices from Dr. Panuwat Lertsitichai and Ms. Suraida Aeesoa. In addition, we gratefully thank Dr. Thongchai Bhongmakapat and Dr. Boonsam Roongpuvapaht, our otolaryngologists, for their tremendous patience enduring this lengthy learning process together.


Original article
peer-reviewed

Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures


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Original article
peer-reviewed

Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures

  • Author Information
    Ake Hansasuta

    Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

    Siriwut Pokanan

    Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

    Pritsana Punyawai

    Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

    Wattana Mahattanakul Corresponding Author

    Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Faculty of Medicine Ramathibodi Hospital, Mahidol University ethic review committee clearance issued approval ID 10-55-34. With approval from the institutional review committee, retrospective analysis of the ETSS records was conducted. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

    Acknowledgements

    The authors would like to express our sincere gratitude for major assistance in statistical analysis along with valuable advices from Dr. Panuwat Lertsitichai and Ms. Suraida Aeesoa. In addition, we gratefully thank Dr. Thongchai Bhongmakapat and Dr. Boonsam Roongpuvapaht, our otolaryngologists, for their tremendous patience enduring this lengthy learning process together.


    Article Information

    Published: January 01, 2018

    DOI

    10.7759/cureus.2010

    Cite this article as:

    Hansasuta A, Pokanan S, Punyawai P, et al. (January 01, 2018) Evolution of Technique in Endoscopic Transsphenoidal Surgery for Pituitary Adenoma: A Single Institution Experience from 220 Procedures . Cureus 10(1): e2010. doi:10.7759/cureus.2010

    Publication history

    Received by Cureus: December 08, 2017
    Peer review began: December 16, 2017
    Peer review concluded: December 28, 2017
    Published: January 01, 2018

    Copyright

    © Copyright 2018
    Hansasuta et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Introduction

Endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA) has been a recent shift from the traditional microscopic technique. Although some literature demonstrated superiority of ETSS over the microscopic method and some evaluated mono- vs. binostril access within the ETSS, none had explored the potential influence of dedicated instrument, as this procedure had evolved, on patients’ outcomes when compared to traditional microscopic tools.

Objective

To investigate our own clinical and radiographic outcomes of ETSS for PA with its technical evolution over time as well as a significance of, having vs. lacking, the special endoscopic tools.

Methods

Included patients underwent ETSS for PA performed by the first author (AH). Prospectively recorded patients’ data concerning pre-, intra- and postoperative clinical and radiographic assessments were subject to analysis. The three groups of differently evolving ETSS techniques, beginning with mononostril (MN) to binostril ETSS with standard microsurgical instruments (BN1) and, lastly, binostril ETSS with specially-designed endoscopic tools (BN2), were examined for their impact on the intra- and, short- and long-term, postoperative results. Also, the survival after ETSS for PA, as defined by the need for reintervention in each technical group, was appraised.

Results

From January 2006 to 2012, there were 47, 101 and 72 ETSS, from 183 patients, in the MN, BN1 and BN2 cohorts, respectively. Significant preoperative findings were greater proportion of patients with prior surgery (p=0.01) and tumors with parasellar extension (p=0.02) in the binostril (BN1&2) than the MN group. Substantially shorter operative time and less amount of blood loss were evident as our technique had evolved (p<0.001). Despite higher incidence, and more advanced grades, of cerebrospinal fluid leakage in the binostril groups (p < 0.001), the requirement for post-ETSS surgical repair was less than the mononostril cohort (p=0.04). At six-month follow-up (n=214), quantitative radiographic outcome analysis was markedly superior in BN2. Consequently, long-term result was better in this latest technical group. Important negative risk factors, from multivariate Cox regression analysis, were prior surgery, Knosp grade, and firm tumor while BN1, BN2 and percentages of anteroposterior dimension PA removal had positive effect on longer survival.

Conclusion

The evolution of technique for ETSS for PA from MN to BN2 has shown its efficacy by improving intra- and postoperative outcomes in our study cohorts. Based on our results, not only that a neurosurgeon, wishing to start performing ETSS, should enroll in a formal fellowship training but he/she should also utilize advanced endoscopic tools, as we have proved its superior results in dealing with PA. 



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Ake Hansasuta, M.D., Associate Professor

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Siriwut Pokanan

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Pritsana Punyawai

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Wattana Mahattanakul, M.D.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

For correspondence:
wattana.mah@mahidol.ac.th

Ake Hansasuta, M.D., Associate Professor

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Siriwut Pokanan

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Pritsana Punyawai

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Wattana Mahattanakul, M.D.

Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University

For correspondence:
wattana.mah@mahidol.ac.th