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TRANSSPHENOIDAL APPROACHES IN PITUITARY TUMOR
SURGERY . A REVIEW
.ivko Gnjidiæ , Tomislav Sajko , Nenad Kudeliæ and Ma.a Malenica
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University Department of Neurosurgery, University Department of Pediatrics, Sestre milosrdnice University
Hospital, Zagreb, Croatia
SUMMARY . Transsphenoidal approach to pituitary tumors was for a long time reserved for
sellar region tumors, whereas tumors expanding into extrasellar region were treated by
transcranial approach. With the development of surgical equipment and gaining surgical
experience, indications for the transsphenoidal approach and its modifications have become
wider and ever more frequently used for pituitary tumors with extrasellar expansion. During the
twenty-five years of performing pituitary surgery, we have operated on more than 1400 tumors of
the sellar region using the transsphenoidal approach and its modifications. The novel
transsphenoidal endoscopic approach is strongly taking more place in pituitary surgery,
advancing
of the standard
transsphenoidal approach. A review is presented of
Fig. 1. The
width the
of possibilities
viewing possibilities
to the
surgical approaches to pituitary tumors.
Key
Pituitary
surgery;
Skull base neoplasms . surgery; Neurosurgical
medial part
of words:
the skull
baseneoplasms
provided . by
modified
procedures
transsphenoidal approach.
Since Sir Victor Horsley, a famous British neurosur-95% of pituitary tumors are treated via transsphenoidal geon, had
performed the first surgery of pituitary tumor approach, whereas the rest of 5% are treated transcranitranscranially in
1904 in London, many surgeons accept-ally . ed this approach . After the Viennese surgeon Schloffer Very few
surgical approaches remained unchanged demonstrated the great practical value of the sphenoid almost throughout
the 20 century as the transsphenoibone sinus as the easiest way to reach the pituitary gland dal approach to pituitary
tumors did. This fact speaks in 1906, he performed the first transnasal transsphenoi-for itself and for the brilliant idea
of Schloffer to use the dal surgery of a pituitary tumor in 1907 in Innsbruck . natural cavities of the nose and the
sphenoid bone to After the initial success, a great number of surgeons and approach the pituitary gland .
otorhinolaryngologists accepted this approach with some Transsphenoidal approach was for a long time used
modifications depending on the surgical equipment and for the tumors located in the sellar region, whereas the skills
of the surgeon. From the beginning, this approach extrasellarly expanding lesions were treated transcraniwas in
accordance with the minimally invasive concept ally. In the last 25 years, due to the development of sur-and should be
regarded as its ancestor. This approach gical equipment and operative techniques, indications
4
1
th
2,3
5,6
experienced a great number of technical ameliorations for the transsphenoidal approach have grown
larger, ex-through which its use overwhelmed surgical treatment panding to lesions of the clivus,
7,8
cavernous sinus and suof not only pituitary tumors but also of other pathology prasellar region . of the
sellar and parasellar region. Nowadays, more than Widening of the transsphenoidal approach to treat
pathological lesions of the clivus and parasellar region Correspondence
to: Head Doctor .ivko Gnjidiæ, MD, PhD, University have been described in detail by Couldwell and Weis . Department
of Neurosurgery, Sestre milosrdnice University Hospital,
Using a combination of various speculum positions and
Vinogradska c. 29, HR-10000 Zagreb, Croatia
asymmetrical retractors, visualization of different parts
E-mail: [email protected] of the skull base has been achieved and bone resections
Received September 26, 2005, accepted in revised form February 23, can be enlarged in the superior, inferior and
lateral way
9
ard transsphenoidal approach nor transcranial
approach allows for good visualization of the
cavernous sinus. Fraioli et al. have described the
transmaxillosphenoidal approach to lesions located
at the medial border of the cavernous sinus. This
approach allows for direct visualization of the
intracavernous portion of the internal carotid artery
during tumor removal . Arita et al. report on the
oblique transsphenoidal approach for removal of
pituitary tumors expanding into the medial part of
the cavernous sinus using a modified speculum
which allows for good visualization of the lateral
border of the sphenoid sinus and the medial part of
the cavernous sinus . Kitano and Tanada reach the
tumors located in the parasellar region by opening
the sphenoid sinus and the posterior ethmoid sinus
on the tumor
side
. Analyzing all approach
the aboveit is possible to remove the
(Fig. 1). With this modified,
widened
transsphenoidal
mentioned
modalities,
we haveapproach
performed
expanding toward the parasellar and suprasellar region. Using this modification
of the
transsphenoidal
wethe
removed 17 clivus tumors
so-called
.oblique
transsphenoethmoidal
predominantly chordomas. Suprasellar tumors, without enlargement of the
sella turcica
(craniopharyngeomas
andapproach.
ectopic suprasellar adenom
23 cases
1996. Two
different modalities
in
attached to the infundibulum), were successfully removed by Kuory and in
Mason
usingsince
the modified
transsphenoidal
approach
. The same
expanding
the pituitary
tumor
into the cavernous
modification is described by Kato, naming it the transsphenoido-transtuberculum
sellae
approach,
emphasizing
its use in dealing with small le
sinus
been recognized:
and intact . The possibility
located above the diaphragma sellae and attached to the infundibulum with
thehave
possibility
to keep the indentation
adenohypophysis
infiltration.
Using
the
standard
trans-sphenoidal
removal of lesions located medially in the suprasellar region using the modified transsphenoidal approach has been described by Kaptain et a
approach
it is possible
to remove
tumors
reaching
emphasize that it carries more complications than the standard transsphenoidal
approach
. Being
aware of
the potential
hazards of this appro
the cavernous sinus borders but not invading it.
used it in only two cases.
Invasion of the cavernous sinus by tumorous tissue
is a complicated problem, especially in cases of
hormonally active tumors. It is often possible to
reduce tumors invading the cavernous sinus using
the standard trans-sphenoidal approach, although it
does not allow for good visualization of the
cavernous sinus structures. Transcranial intradural
or extradural approaches did not yield better results
but enlarged the intraoperative trauma and
complications . On using the oblique
transsphenoethmoidal approach the surgical
corridor is almost the same as in the Fig. 2.
Asymmetrical speculum.
14
15
16
10,11
12
13
19-22
Pituitary tumors frequently infiltrate cavernous sinuses and, in this case, they represent a great
problem and challenge to many neurosurgeons.
Neither stand
Fig. 3. Oblique transsphenoethmoidal approach: (A) minimal osteotomy of the maxilla on the
tumor opposite side; (B) the longer part of the speculum is placed in the sphenoid sinus. The
shorter part is in the posterior ethmoidal sinus. In the middle of the operative field is the medial
artery.
part of the cavernous sinus and intracavernous portion of the internal carotid
standard transsphenoidal approach. After the
sphenoidal sinus is wide open, minimal osteotomy
of the maxilla is done in the inferior lateral angle of
the apertura piriformis, on the tumor-opposite side,
removing the nasal process of the maxilla. The
asymmetrical speculum is brought in the operative
field and placed so that the longer part is in the
sphenoidal sinus on the tumor-opposite side, and
the shorter part of the speculum on the tumor side,
reaching the posterior ethmoidal sinus which is
wide open (Fig. 2). By doing so, the sphenoidal and
ethmoidal sinuses are connected in a single cavity,
and the posterior and lateral border of the
sphenoidal sinus is located in the middle of the
The
bone field
prominence
of the internal carotid artery
operative
(Fig. 3A,B).
and the optical nerve are completely visualized.
Opening the dura in this region, the medial anterior
and inferior part of the cavernous sinus is
approached. There is more bleeding, especially
after the tumor has been removed, but it can be
easily controlled with the use of hemostatic
material.
17
Using the above mentioned approach it is possible
to totally remove the intrasellar and intracavernous
part of the tumor and to visualize the
intracavernous portion of the internal carotid artery.
Cranial nerves are pushed toward the lateral border
of the cavernous sinus and are not exposed to
Closing
is done
as in the standard transsphenoidal
intraoperative
manipulations.
approach. Tumorous cavity is filled with fatty tissue
followed by reconstruction of the anterior wall of the
sella turcica (Fig. 4A,B,C,D).
Our
experience
in
using
the
oblique
transsphenoethmoidal approach is favorable. It
represents a logical pathway, especially in pituitary
tumors invading the cavernous sinus. By this
approach the cavernous sinus is reached
completely extradurally and from the medial side,
i.e. the side of the tumor growth, minimizing the risk
of lesion of intracavernous cranial nerves. Also, the
oblique transseptal approach and opening of the
posterior ethmoidal sinus allows for keeping the
nasal mucosa intact and preventing direct
communication between the nasal bacterial flora
and the operative field . There
23
Fig. 4. Preoperative MRI scans showing invasive pituitary adenoma infiltrating the right cavernous sinus
(A, B, C). The early postoperative CT scan showing fatty tissue in the place of the removed adenoma (D).
are few neurosurgeons skilled to reach this delicate field the logical pathway. It enables, with better
visualizausing the transcranial approach. Even so, there is a high tion and minimal intraoperative trauma,
to completely risk of leaving residual tumor behind that requires fur-remove the tumor or to reduce it to a
size that can be ther surgical, medicamentous treatment or irradiation. further treated radiosurgically.
Modifications of the transsphenoidal approach such as Superior visualization and excellent surgical results
the oblique transsphenoethmoidal approach represent in endoscopic sinus surgery have stimulated
neurosur
geons to explore the use of endoscope in
transsphenoidal surgery . The first use of an endoscope in pituitary
24
surgery was reported by Bushe and Halvers in 1978, but this work remained almost
25
sidual
part of the tumor following the standard
trans-sphenoidal approach, enabling the so-called
.behind the corner look.. In 1982 we used such a
rigid endoscope (sinus scope for straight view and
30 and 70 degree sinus scope) in pituitary surgery
without knowing that Bushe and Havers were doing
the same .
unnoticed . At first, rigid endoscopes or sinus scopes were used to verify any re
26,27
Because of the lack of video camera and often
operating field desterilization we used that
technique only for visualization the tumor cavity
after removal of large extrasellarly extending
tumors. Thanks to data obtained with other forms of
intraoperative control (x-ray, urgent intraoperative
histopathology, 45° mirror examination and
intraoperative hormone level monitoring), we had
good intraoperative control in cases of hormone
secreting adenomas with good postoperative
With
technological
of endoscopic surfunctional
results advancement
.
gery, novel systems of rigid and flexible
endoscopes for use in neurosurgery and pituitary
surgery were developed. Nowadays, endoscope is
mostly being used as an ancillary instrument during
transsphenoidal microsurgery. Yanniv and
Rappaport have described the combined
27-29
approach during which the endoscope was used in
the initial transseptal phase and afterwards
converted into a standard transsphenoidal
approach. This resulted in a reduced postoperative
morbidity, also taking the advantage of
stereoscopic visualization by using the operative
microscope . Further technological development allowed for the
whole transsphenoidal surgery to be performed
endoscopically, even more reducing postoperative
morbidity.
The main advantages of endoscopic approach are
better visualization, the so-called .panoramic view.,
better illumination and magnification. There is no
need of nostril tampons, and the patient could be
released from the hospital at 24 hours
postoperatively . The endoscope is usually
introduced into the left nostril. The use of the
endoscope is facilitated by the placement of a
table-mounted endoscope holder on the left-hand
side of the operative table to free both hands of the
surgeon . Despite the opinion that endoscopic
approach allows for quicker postoperative recovery
and reduces hospital stay, some experienced
pituitary surgeons question this statement . There
are no large series reporting results accomplished
The
maineither
disadvantages
of the
by using
this method
or atranssphenoidal
long-time followenup
doscopic
approach
are
the
lack
of
stereoscopic
of patients submitted to this type of surgery .
view and the lack of instrumentation. Also, it lacks
control in cas
28
28
29
30,31
32
Fig. 5. Giant craniopharyngeoma successfully removed by endoscopy-assisted transsphenoidal approach:
(A) preoperative MRI scan; (B) postoperative MRI scan.
24
es of serious intraoperative bleeding . On the other
hand, the transsphenoidal endoscopic approach
provides many advantages of a minimally invasive
method with satisfactory results.
Worldwide, the transseptal, transsphenoidal
approach is the method of choice in treating most
of the sellar region tumors . This approach has
been developed and modified throughout the 20
century. The endoscopic approach has been
developed over the last decade . Better efficacy
and minimal invasiveness of the transsphenoidal
technique flourish in the hand of a skilled
Nowadays,
two .different surgical approaches play a
neurosurgeon
dominant role in pituitary surgery: microsurgical and
endoscopic, each with its own philosophy.
In-between, there is an endoscopic assisted
transsphenoidal surgery, as a golden compromise
(Fig. 5A,B). The operative microscope allows for an
excellent three-dimensional view and comfortable
surgical manipulation, while the endoscope
provides a closer look and reduces the postoperaA
skilled
in the standard transsphetiveneurosurgeon
recovery period
.
noidal approach could also be trained for the
endoscope use. An inexperienced neurosurgeon
should be trained to be able to perform pituitary
surgery with both modalities.
The objective differences between the two above
mentioned approaches should become clear after
large series of patients treated endoscopically are
reported. Both of these methods are efficient if: the
pathological lesion is successfully identified and
removed; the neurosurgeon works with highly
sophisticated equipment; and the neurosurgeon is
skilled in various operative techniques.
Edward
Laws,
an
experienced
pituitary
neurosurgeon and President of the International
Association of the Pituitary Surgeons, has stated: .It
is important to remember that the goal of pituitary
surgery is not releasing the patient from the
hospital on the first or second postoperative day,
but to successfully remove the tumor. .
At this moment, it remains unclear whether an experienced neurosurgeon can achieve the same
results using either the standard or the endoscopic
transsphenoidal approach. Until now, there is a
small amount of data to make a straight conclusion,
but according to the results published so far, one
can only be impressed with the possibilities the
endoscopic transssphenoidal approach is offering.
33,34
th
35-37
38-40
In our opinion, the advantages of the endoscopic
transsphenoidal approach are very remarkable and
every young neurosurgeon has to be trained to
perform such a surgery. Yet, it has to be
emphasized that the standard microsurgical
transsphenoidal approach still remains the number
one procedure in pituitary tumor surgery worldwide.
The future lies in the complementary use of these
Because
of various
typical and recognizable
two great operative
techniques.
anatomic and topographic markers, the new and
sophisticated method of neuronavigation has a
negligible role in pituitary surgery .
Rarely, the suprasellar and parasellar extending tumors are primarily or after transsphenoidal
reduction operated by transcranial approach. In
these cases we insist on minimally invasive
methods . The radio-surgical method has the
leading place in treating tumor residua in the
cavernous sinus. In the last two years, we
successfully used gamma knife in the treatment of
30 patients .
44,45
4,46,47
48-51
41
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䘀
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最
⸀............................................................................... Sa.etak
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SMJEROVI RAZVOJA KIRUR.KOG LIJEÈENJA TUMORA HIPOFIZE
.. Gnjidiæ, T. Sajko, N. Kudeliæ i M. Malenica
Transsfenoidni pristup tumorima hipofize dugo je bio rezerviran za intraselarne neoplazme, dok se ekstraselarno
pro.irene tumore rje.avalo transkranijskim pristupom. Zahvaljujuæi razvoju kirur.ke opreme i instrumentarija te veæem
iskustvu operatera indikacije za ovaj pristup i njegove modalitete postale su .ire pa se èe.æe rabe i za ekstraselarno
pro.irene tumore. Tijekom 25 godina bavljenja kirurgijom hipofize operirali smo preko 1400 tumora selarne regije
rabeæi transsfenoidni pristup i njegove modalitete. Novi endoskopski transsfenoidni pristup zauzima sve vi.e mjesta u
kirur.kom lijeèenju hipofize te tako poveæava lepezu moguænosti pro.irenog transsfenoidnog pristupa. Prikazani su
kirur.ki pristupi lijeèenju tumora hipofize.
Kljuène rijeèi: Neoplazme hipofize . kirurgija; Neoplazme baze lubanje . kirurgija; Neurokirur.ki
zahvati