Surgical approach to pituitary tumors

Pituitary surgery is a continuously evolving specialty of neurosurgery that requires precise anatomical knowledge, technical skills, and an integrated appreciation of pituitary pathophysiology. It involves close cooperation between different specialists, i.e., the endocrinologist, neurosurgeon, neuroradiologist, pathologist, ophthalmologist, and others. It is currently possible to manage many of the different pituitary syndromes with more than one option, including medical, surgical, and radiotherapeutic options, either alone or in various combinations. In recent decades, the transsphenoidal midline route became the standard approach to the pituitary area, this being a less traumatic direct route to the sella, avoiding brain retraction and providing excellent visualization, with a lower morbidity and mortality rate as compared to transcranial procedures. Most pituitary adenomas can be managed and removed through a standard transsphenoidal approach, either microscopic or endoscopic. More recently, the introduction of the endoscope in the extended endoscopic endonasal approach has become more widespread. Here we report current indications and give a step-by-step account of the surgical techniques used in pituitary surgery, focusing on the "dangerous keypoints". We also describe possible complications of each kind of procedure.