Hypothalamus-sparing surgery in craniopharyngiomas: Oncological and hypothalamic long-term outcomes

Although craniopharyngiomas (CPs) are typically histologically benign and can be cured by radical removal, they are associated with a high level of operative morbidity due to their deep-seated, highly functional location. During the previous decades, the surgical philosophy has changed from radical removal to more restrained strategies of subtotal resection followed by radiotherapy to preserve the integrity of the hypothalamus. However, with improved surgical techniques and the availability of novel molecular diagnostic and therapeutic tools, the concept of hypothalamus-sparing CP surgery should be revised. From an oncological point of view, gross total resection (GTR) should be attempted as it can provide lifelong freedom from disease. However, less than total resection is necessary in cases of hypothalamic infiltration, as hypothalamic damage is unacceptable. The extended transsphenoidal approach (eTSA) promises reduced hypothalamic manipulation compared to the traditional transcranial approach (TCA). There is strong consensus that hypothalamic morbidity is reduced if CP surgery is performed in specialized high-volume neurosurgical centers. Novel targeted therapies (TT) in PCP enables the possibility of biopsy only in selected patients with high-risk CP. This review aims to provide a practical approach to current strategies and concepts in hypothalamus-sparing surgery for CP, with special regard to oncological outcome, hypothalamic and endocrine morbidity, and quality of life.