AIM: To compare microsurgical technique (mTSS) and endoscopic technique (eTSS) in the treatment of non-functioning pituitary adenomas (NFPAs). METHODS: We retrospectively evaluated the charts of 50 patients who underwent either mTSS or eTSS for NFPA in the Department of Neurosurgery, University Hospital Hradec Kralove from 2013 to 2019. We enrolled all patients who were not treated by postoperative adjuvant radiotherapy and who underwent at least two regular postoperative magnetic resonance imaging (MRI) tests. We compared the groups in terms of the extent of resection, surgery duration, blood loss, complication rate, overall clinical effect on the endocrinological and ophthalmological deficit, and postoperative growth pattern of the residual tumor mass. RESULTS: The mTSS group had significantly shorter surgical time (75 min vs 127 min, P<0.001) and lower perioperative blood loss (156 mL vs 256 mL, P=0.027). The groups did not significantly differ in the extent of resection, overall clinical or hormonal effect, and the complication rate. The extent of resection did not correlate with tumor consistency, while the tumor growth rate did not correlate with age or Ki-67 expression. CONCLUSIONS: There was no major difference between the approaches in surgery radicality or safeness. However, eTSS remains the method of choice due to its potentially higher postoperative preservation of hormonal functions.

Tomáš Česák Department of Neurosurgery University Hospital Hradec Kralove Sokolská 581 500 05 Hradec Králové Czech Republic

Zobrazit více v PubMed

Abe T, Ludecke DK, Saeger W. Clinically nonsecreting pituitary adenomas in childhood and adolescence. Neurosurgery. 1998;42:744–51. doi: 10.1097/00006123-199804000-00037. PubMed DOI

Kovacs K, Ryan N, Horvath E, Singer W, Ezrin C. Pituitary adenomas in old age. J Gerontol. 1980;35:16–22. doi: 10.1093/geronj/35.1.16. PubMed DOI

Shou XF, Li SQ, Wang YF, Zhao Y, Jia PF, Zhou LF. Treatment of pituitary adenomas with a transsphenoidal approach. Neurosurgery. 2005;56:249–56. doi: 10.1227/01.NEU.0000147976.06937.1D. PubMed DOI

Huang BY, Castillo M. Nonadenomatous tumors of the pituitary and sella turcica. Top Magn Reson Imaging. 2005;16:289–99. doi: 10.1097/01.rmr.0000224685.83629.18. PubMed DOI

Česák T, Náhlovský J, Látr I, Čáp J, Ryška P. Nádorová onemocnění hypofýzy. In: Náhlovský J. Neurochirurgie Praha: Galén; 2006: p 155-174.

Lloyd RV, Osamura RY, Klöppel G, Rosai J, Bosman FT, Jaffe ES, et al. WHO classification of tumours of endocrine organs. International Agency for Research on Cancer. 2017.

Ntali G, Wass JA. Epiemiology, clinical presentation and diagnosis of non-functioning pituitary adenomas. Pituitary. 2018;21:111–8. doi: 10.1007/s11102-018-0869-3. PubMed DOI

Tjornstrand A, Gunnarsson K, Evert M, Holmberg E, Ragnarsson O, Rosen T, et al. The incidence rate of pituitary adenomas in western Sweden for the period 2001-2011. Eur J Endocrinol. 2014;171:519–26. doi: 10.1530/EJE-14-0144. PubMed DOI

Olsson DS, Nilsson AG, Bryngelsson IL, Trimpou P, Johannsson G, Andersson E. Excess mortality in women and young adults with nonfunctioning pituitary adenoma: a Swedish nationwide study. J Clin Endocrinol Metab. 2015;100:2651–8. doi: 10.1210/jc.2015-1475. PubMed DOI

Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997;40:225–36. doi: 10.1097/00006123-199702000-00001. PubMed DOI

Hardy J. Transsphenoidal hypophysectomy. J Neurosurg. 1971;34:582–94. doi: 10.3171/jns.1971.34.4.0582. PubMed DOI

Patel SK, Husain Q, Eloy JA, Couldwell WT, Liu JK. Norman Dott, Gerard Guiot, and Jules Hardy: key players in the resurrection and preservation of transsphenoidal surgery. Neurosurg Focus. 2012;33:E6. doi: 10.3171/2012.6.FOCUS12125. PubMed DOI

Wilson CB. Surgical management of pituitary tumors. J Clin Endocrinol Metab. 1997;82:2381–5. doi: 10.1210/jcem.82.8.4188. PubMed DOI

Almutairi RD, Muskens IS, Cote DJ, Dijkman MD, Kavouridis VK, Crocker E, et al. Gross total resection of pituitary adenomas after endoscopic vs microscopic transsphenoidal surgery: a meta-analysis. Acta Neurochir (Wien) 2018;160:1005–21. doi: 10.1007/s00701-017-3438-z. PubMed DOI PMC

Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg. 1998;41:66–73. doi: 10.1055/s-2008-1052019. PubMed DOI

Dallapiazza RF, Jane JA., Jr Outcomes of endoscopic transsphenoidal pituitary surgery. Endocrinol Metab Clin North Am. 2015;44:105–15. doi: 10.1016/j.ecl.2014.10.010. PubMed DOI

Dusick JR, Esposito F, Mattozo CA, Chaloner C, McArthur DL, Kelly DF. Endonasal transsphenoidal surgery: the patient’s perspective-survey results from 259 patients. Surg Neurol. 2006;65:332–41. doi: 10.1016/j.surneu.2005.12.010. PubMed DOI

Little AS, Kelly DF, White WL, Gardner PA, Fernandez-Miranda JC, et al. Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER)Study J Neurosurg 20191–11. PubMed

Poczos P, Kurbanov A, Keller JT, Zimmer LA. Medial and superior orbital decompression: improving access for endonasal endoscopic frontal sinus surgery. Ann Otol Rhinol Laryngol. 2015;124:987–95. doi: 10.1177/0003489415595423. PubMed DOI

Tabaee A, Anand VK, Barron Y, Hiltzik DH, Brown SM, Kacker A, et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg. 2009;111:545–54. doi: 10.3171/2007.12.17635. PubMed DOI

Lipina MR, Matoušek MP, Paleček MT. Endoskopický transnazální přístup k lézím selární oblasti. Endoskopie. 2011;20:57–61.

Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery. 1993;33:610–7. doi: 10.1227/00006123-199310000-00008. PubMed DOI

Tanaka Y, Hongo K, Tada T, Sakai K, Kakizawa Y, Kobayashi S. Growth pattern and rate in residual nonfunctioning pituitary adenomas: correlations among tumor volume doubling time, patient age, and MIB-1 index. J Neurosurg. 2003;98:359–65. doi: 10.3171/jns.2003.98.2.0359. PubMed DOI

Asemota AO, Ishii M, Brem H, Gallia GL. Comparison of complications, trends, and costs in endoscopic vs microscopic pituitary surgery: analysis from a US Health Claims Database. Neurosurgery. 2017;81:458–72. doi: 10.1093/neuros/nyx350. PubMed DOI

Bokhari AR, Davies MA, Diamond T. Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve. Br J Neurosurg. 2013;27:44–9. doi: 10.3109/02688697.2012.709554. PubMed DOI

Chi F, Wang Y, Lin Y, Ge J, Qiu Y, Guo L. A learning curve of endoscopic transsphenoidal surgery for pituitary adenoma. J Craniofac Surg. 2013;24:2064–7. doi: 10.1097/SCS.0b013e3182a24328. PubMed DOI

Smith SJ, Eralil G, Woon K, Sama A, Dow G, Robertson I. Light at the end of the tunnel: the learning curve associated with endoscopic transsphenoidal skull base surgery. Skull Base. 2010;20:69–74. doi: 10.1055/s-0029-1238214. PubMed DOI PMC

Kassis S, De Battista JC, Raverot G, Jacob M, Simon E, Rabilloud M, et al. Endoscopy versus microsurgery: results in a consecutive series of nonfunctioning pituitary adenomas. . Neurochirurgie. 2009;55:607–15. doi: 10.1016/j.neuchi.2009.05.003. PubMed DOI

Berkmann S, Schlaffer S, Nimsky C, Fahlbusch R, Buchfelder M. Follow-up and long-term outcome of nonfunctioning pituitary adenoma operated by transsphenoidal surgery with intraoperative high-field magnetic resonance imaging. Acta Neurochir (Wien) 2014;156:2233–43. doi: 10.1007/s00701-014-2210-x. PubMed DOI

de Divitiis E, Cappabianca P. Endoscopic endonasal transsphenoidal surgery. Adv Tech Stand Neurosurg. 2002;27:137–77. doi: 10.1007/978-3-7091-6174-6_4. PubMed DOI

Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery. 2008;62:1006–17. doi: 10.1227/01.neu.0000325862.83961.12. PubMed DOI

DeKlotz TR, Chia SH, Lu W, Makambi KH, Aulisi E, Deeb Z. Meta-analysis of endoscopic versus sublabial pituitary surgery. Laryngoscope. 2012;122:511–8. doi: 10.1002/lary.22479. PubMed DOI

Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M. Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery. 2005;56:1222–33, discussion 1233. doi: 10.1227/01.NEU.0000159647.64275.9D. PubMed DOI

Rotenberg B, Tam S, Ryu WH, Duggal N. Microscopic versus endoscopic pituitary surgery: a systematic review. Laryngoscope. 2010;120:1292–7. doi: 10.1002/lary.20949. PubMed DOI

Singh H, Essayed WI, Cohen-Gadol A, Zada G, Schwartz TH. Resection of pituitary tumors: endoscopic versus microscopic. J Neurooncol. 2016;130:309–17. doi: 10.1007/s11060-016-2124-y. PubMed DOI

Strychowsky J, Nayan S, Reddy K, Farrokhyar F, Sommer D. Purely endoscopic transsphenoidal surgery versus traditional microsurgery for resection of pituitary adenomas: systematic review. J Otolaryngol Head Neck Surg. 2011;40:175–85. PubMed

Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH. cavernous sinus invasion in pituitary adenomas: systematic review and pooled data meta-analysis of radiologic criteria and comparison of endoscopic and microscopic surgery. World Neurosurg. 2016;96:36–46. doi: 10.1016/j.wneu.2016.08.088. PubMed DOI

Messerer M, De Battista JC, Raverot G, Kassis S, Dubourg J, Lapras V, et al. Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus. 2011;30:E11. doi: 10.3171/2011.1.FOCUS10308. PubMed DOI

Gao Y, Zhong C, Wang Y, Xu S, Guo Y, Dai C, et al. Endoscopic versus microscopic transsphenoidal pituitary adenoma surgery: a meta-analysis. World J Surg Oncol. 2014;12:94. doi: 10.1186/1477-7819-12-94. PubMed DOI PMC

Česák T, Náhlovský J, Hosszú T, Řehák S, Látr I, Němeček S, et al. Longitudinální sledování růstu pooperačních reziduí afunkčních adenomů hypofýzy. Cesk Slov Neurol. 2009;72:105.

Gejman R, Swearingen B, Hedley-Whyte ET. Role of Ki-67 proliferation index and p53 expression in predicting progression of pituitary adenomas. Hum Pathol. 2008;39:758–66. doi: 10.1016/j.humpath.2007.10.004. PubMed DOI

Honegger J, Prettin C, Feuerhake F, Petrick M, Schulte-Monting J, Reincke M. Expression of Ki-67 antigen in nonfunctioning pituitary adenomas: correlation with growth velocity and invasiveness. J Neurosurg. 2003;99:674–9. doi: 10.3171/jns.2003.99.4.0674. PubMed DOI

Hsu DW, Hakim F, Biller BM, de la Monte S, Zervas NT, Klibanski A, et al. Significance of proliferating cell nuclear antigen index in predicting pituitary adenoma recurrence. J Neurosurg. 1993;78:753–61. doi: 10.3171/jns.1993.78.5.0753. PubMed DOI

Matousek P, Buzrla P, Reguli S, Krajca J, Dvorackova J, Lipina R. Factors that predict the growth of residual nonfunctional pituitary adenomas: correlations between relapse and cell cycle markers. BioMed Res Int. 2018;2018:1876290. doi: 10.1155/2018/1876290. PubMed DOI PMC

Steno A, Bocko J, Rychly B, Chorvath M, Celec P, Fabian M, et al. Nonfunctioning pituitary adenomas: association of Ki-67 and HMGA-1 labeling indices with residual tumor growth. Acta Neurochir (Wien) 2014;156:451–61. doi: 10.1007/s00701-014-1993-0. PubMed DOI

Trouillas J, Roy P, Sturm N, Dantony E, Cortet-Rudelli C, Viennet G, et al. A new prognostic clinicopathological classification of pituitary adenomas: a multicentric case-control study of 410 patients with 8 years post-operative follow-up. Acta Neuropathol. 2013;126:123–35. doi: 10.1007/s00401-013-1084-y. PubMed DOI

Turner HE, Nagy Z, Sullivan N, Esiri MM, Wass JA. Expression analysis of cyclins in pituitary adenomas and the normal pituitary gland. Clin Endocrinol (Oxf) 2000;53:337–44. doi: 10.1046/j.1365-2265.2000.01088.x. PubMed DOI

Raverot G, Burman P, McCormack A, Heaney A, Petersenn S, Popovic V, et al. European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas. Eur J Endocrinol. 2018;178:G1–24. doi: 10.1530/EJE-17-0796. PubMed DOI

Saeger W, Petersenn S, Schofl C, Knappe UJ, Theodoropoulou M, Buslei R, et al. Emerging histopathological and genetic parameters of pituitary adenomas: clinical impact and recommendation for future WHO classification. Endocr Pathol. 2016;27:115–22. doi: 10.1007/s12022-016-9419-6. PubMed DOI

Trouillas J, Burman P, McCormack A, Petersenn S, Popovic V, Dekkers O, et al. Aggressive pituitary tumours and carcinomas: two sides of the same coin? Eur J Endocrinol. 2018;178:C7–9. doi: 10.1530/EJE-18-0250. PubMed DOI

Jakobsson KE, Petruson B, Lindblom B. Dynamics of visual improvement following chiasmal decompression Quantitative pre- and postoperative observations. Acta Ophthalmol Scand. 2002;80:512–6. doi: 10.1034/j.1600-0420.2002.800510.x. PubMed DOI

Semela L, Yang EB, Hedges TR, Vuong L, Odel JG, Hood DC. Multifocal visual-evoked potential in unilateral compressive optic neuropathy. Br J Ophthalmol. 2007;91:445–8. doi: 10.1136/bjo.2006.097980. PubMed DOI PMC

Karppinen A, Kivipelto L, Vehkavaara S, Ritvonen E, Tikkanen E, Kivisaari R, et al. Transition from microscopic to endoscopic transsphenoidal surgery for nonfunctional pituitary adenomas. World Neurosurg. 2015;84:48–57. doi: 10.1016/j.wneu.2015.02.024. PubMed DOI

Monteiro ML, Zambon BK, Cunha LP. Predictive factors for the development of visual loss in patients with pituitary macroadenomas and for visual recovery after optic pathway decompression. Can J Ophthalmol. 2010;45:404–8. doi: 10.3129/i09-276. PubMed DOI

Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V, Grasso V, et al. The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology. 2006;83:240–8. doi: 10.1159/000095534. PubMed DOI

Masopust V, Netuka D, Benes V, Bradac O, Marek J, Hana V. Endonasal endoscopic pituitary adenoma resection: preservation of neurohypophyseal function. J Neurol Surg A Cent Eur Neurosurg. 2014;75:336–42. doi: 10.1055/s-0034-1368687. PubMed DOI

Razak AA, Horridge M, Connolly DJ, Warren DJ, Mirza S, Muraleedharan V, et al. Comparison of endoscopic and microscopic trans-sphenoidal pituitary surgery: early results in a single centre. Br J Neurosurg. 2013;27:40–3. doi: 10.3109/02688697.2012.703353. PubMed DOI

Novák V, Hrabálek L, Fryšák Z, Hoza J, Hučko C, Krahulík D, et al. Výsledky endokrinních funkcí hypofýzy po transsfenoidálních operacích afunkčních makroadenomů. Ces Slov Neurol Neurochir. 2017;80:286–90.

Nomikos P, Ladar C, Fahlbusch R, Buchfelder M. Impact of primary surgery on pituitary function in patients with non-functioning pituitary adenomas–a study on 721 patients. Acta Neurochir (Wien) 2004;146:27–35. doi: 10.1007/s00701-003-0174-3. PubMed DOI

Jane JA, Laws ER. The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg. 2001;193:651–9. doi: 10.1016/S1072-7515(01)01101-2. PubMed DOI

Nelson AT, Tucker HS, Becker DP. Residual anterior pituitary function following transsphenoidal resection of pituitary macroadenomas. J Neurosurg. 1984;61:577–80. doi: 10.3171/jns.1984.61.3.0577. PubMed DOI

Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002;97:293–8. doi: 10.3171/jns.2002.97.2.0293. PubMed DOI

Majovsky M, Astl J, Kovar D, Masopust V, Benes V, Netuka D. Olfactory function in patients after transsphenoidal surgery for pituitary adenomas-a short review. Neurosurg Rev. 2019;42:395–401. doi: 10.1007/s10143-018-1034-1. PubMed DOI

Griffith HB, Veerapen R. A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurg. 1987;66:140–2. doi: 10.3171/jns.1987.66.1.0140. PubMed DOI

Cho DY, Liau WR. Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg Neurol. 2002;58:371–6. doi: 10.1016/S0090-3019(02)00892-3. PubMed DOI

Sameš M, Vachata P, Saur K, Budíková M. Přímý transnazální miniinvazivní přístup pro mikrochirurgickou resekci adenomů hypofýzy. Cesk Slov Neurol. 2005;2006:68.

Náhlovský J, Česák T, Látr I, Čáp J, Žižka J, Krajina A. Komplikace transsfenoidálních operací u našich nemocných-příčiny, řešení. Cesk Slov Neurol. (2004): 67.

Laws ER. Vascular complications of transsphenoidal surgery. Pituitary. 1999;2:163–70. doi: 10.1023/A:1009951917649. PubMed DOI

Cavallo LM, Briganti F, Cappabianca P, Maiuri F, Valente V, Tortora F, et al. Hemorrhagic vascular complications of endoscopic transsphenoidal surgery. Minim Invasive Neurosurg. 2004;47:145–50. doi: 10.1055/s-2004-818489. PubMed DOI

Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol. 1997;18:655–65. PubMed PMC

Wakai S, Fukushima T, Teramoto A, Sano K. Pituitary apoplexy: its incidence and clinical significance. J Neurosurg. 1981;55:187–93. doi: 10.3171/jns.1981.55.2.0187. PubMed DOI

Webb SM, Rigla M, Wagner A, Oliver B, Bartumeus F. Recovery of hypopituitarism after neurosurgical treatment of pituitary adenomas. J Clin Endocrinol Metab. 1999;84:3696–700. doi: 10.1210/jcem.84.10.6019. PubMed DOI

Optical coherence tomography and visual evoked potentials in evaluation of optic chiasm decompression