Surgical management of selected pituitary macroadenomas using extended endoscopic endonasal transsphenoidal approach:...

The endoscopic transsphenoidal approach is commonly used surgical approach for pituitary adenomas. However, adenomas with dumbbell configuration, pure suprasellar location, and fibrous consistency are difficult to remove by this approach. Recently, the extended endoscopic endonasal approach (EEEA) has been utilized to excise this subgroup of pituitary adenomas successfully.

Between January 2009 and December 2011, 13 patients with pituitary macroadenomas were treated with EEEA. The tumor subgroups included: Dumbbell tumor configuration (4), pure suprasellar tumor location (2), and large suprasellar tumors with subfrontal extension (2). Five patients had fibrous/recurrent tumors and required addition of transtubercular-transplanum extension to the standard endoscopic endonasal exposure for radical resection.

The tumor removal was gross total in 8 (61.5%) patients, subtotal in 4 (30.7%), and partial in 1 (7.7%) patient. Clinical improvement was observed in almost all patients, immediate relief in headaches in 88% and normalization of vision in 90% of patients with pre-operative visual disturbances. Three patients with secreting adenomas, two with growth hormone-secreting adenomas and one with prolactin-secreting adenoma, had normalization of hormonal status. Three patients developed temporary diabetes insipidus two patients suffered transient ischemic attacks and one patient with a recurrent giant pituitary adenoma experienced a serious injury to the perforating artery. Four patients (30.7%) developed post-operative cerebrospinal rhinorrhea and two patients required surgical repair.

Our early experience suggests that the EEEA offers a potentially viable treatment option in certain pituitary tumors which are difficult to remove by the standard endoscopic approaches. However, longer follow-up and larger series are needed to establish the efficacy of this approach.