, Volume 17, Issue 4, pp 307–319 | Cite as

Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients

  • Alessandro Paluzzi
  • Juan C. Fernandez-Miranda
  • S. Tonya Stefko
  • Sue Challinor
  • Carl H. Snyderman
  • Paul A. Gardner



To report the results of a consecutive series of patients who underwent an endoscopic endonasal approach (EEA) for resection of a pituitary adenoma and compare them to previous series of microscopic and endoscopic approaches.


A retrospective review of clinical and radiographic outcomes of a consecutive series of patients operated at our center between 2002 and 2011 was performed.


555 patients underwent an EEA for removal of a pituitary adenoma. The mean follow up was 3.1 years (range 3 months to 9.5 years); 36 were lost to follow up. Ninety-one (17.5 %) harbored recurrent adenomas. An expanded approach to reach the supra-, para- and infra-sellar spaces was employed in 290 patients (55.9 %). Reconstruction with a nasal septal flap was used in 238 cases (65.6 %). The rate of gross total resection was 65.3 % in the 359 patients with non-functioning adenomas. The remission rates with EEA alone were 82.5 % in the 57 ACTH-secreting adenomas, 65.3 % in the 49 GH-secreting adenomas and 54.7 % in the 53 prolactinomas. Of the 237 patients presenting with visual loss, 190 (80.2 %) improved or normalized, 41 (17.3 %) remained unchanged and 4 (1.7 %) experienced transient visual deterioration due to postoperative apoplexy. In addition, no patient without preexisting visual loss suffered new visual decline. The overall post-operative CSF leak rate was 5 % and this decreased to 2.9 % after the introduction of reconstruction with the naso-septal flap. Two patients (0.3 %) had an ICA injury.


The EEA is a safe and effective way to surgically approach pituitary adenomas, particularly in recurrent tumors, those with supra-sellar extension or cavernous sinus invasion. The remission and complication rates are comparable or favorable compared with those reported in previous series of microscopic and endoscopic approaches.


Acromegaly Adenoma Cushing’s disease Endoscopy Pituitary Prolactinoma Transsphenoidal 


Conflict of interest



  1. 1.
    Guiot G, Rougerie J, Fourestier M et al (1963) Explorations endoscopiques intracraniennes. Presse Med 71:1225–1228PubMedGoogle Scholar
  2. 2.
    Jho HD, Carrau RL (1997) Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 87(1):44–51PubMedCrossRefGoogle Scholar
  3. 3.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19(1):E3PubMedGoogle Scholar
  4. 4.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19(1):E4PubMedGoogle Scholar
  5. 5.
    Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely trans- nasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19(1):E6PubMedGoogle Scholar
  6. 6.
    Cappabianca P, Cavallo LM, Colao A, de Divitiis E (2002) Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97(2):293–298PubMedCrossRefGoogle Scholar
  7. 7.
    Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V, Grasso V, Faustini Faustini M (2006) The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology 83:240–248PubMedCrossRefGoogle Scholar
  8. 8.
    Dehdashti AR, Ganna A, Karabatsou K, Gentili F (2008) Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 62(5):1006–1015 (discussion 1015-7)PubMedCrossRefGoogle Scholar
  9. 9.
    Gondim JA, Schops M, de Almeida JP, de Albuquerque LA, Gomes E, Ferraz T, Barroso FA (2010) Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary 13(1):68–77 (Epub 2009 Aug 21)PubMedCrossRefGoogle Scholar
  10. 10.
    Hofstetter CP, Shin BJ, Mubita L, Huang C, Anand VK, Boockvar JA, Schwartz TH (2011) Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas. Neurosurg Focus 30(4):E10PubMedCrossRefGoogle Scholar
  11. 11.
    Alahmadi H, Dehdashti AR, Gentili F (2012) Endoscopic endonasal surgery in recurrent and residual pituitary adenomas after microscopic resection. World Neurosurg 77(3–4):540–547Google Scholar
  12. 12.
    Powell M (2009) Microscopic and endoscopic pituitary surgery. Acta Neurochir 151:723–728PubMedCrossRefGoogle Scholar
  13. 13.
    Giustina A, Chanson P, Bronstein MD, Klibanski A, Lamberts S, Casanueva FF, Trainer P, Ghigo E, Ho K, Melmed S (2010) Acromegaly consensus group. A consensus on criteria for cure of acromegaly. J Clin Endocrinol Metab 95:3141–3148PubMedCrossRefGoogle Scholar
  14. 14.
    Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33(4):610–617PubMedCrossRefGoogle Scholar
  15. 15.
    Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116(10):1882–1886PubMedCrossRefGoogle Scholar
  16. 16.
    Ebersold MJ, Quast LM, Laws ER Jr, Scheithauer B, Randall RV (1986) Long-term results in transsphenoidal removal of nonfunctioning pituitary adenomas. J Neurosurg 64:713–719PubMedCrossRefGoogle Scholar
  17. 17.
    Zada G, Kelly DF, Cohan P, Wang C, Swerdloff R (2003) Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety and patients impressions. J Neurosurg 98:350–358PubMedCrossRefGoogle Scholar
  18. 18.
    Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M (2005) Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 56(6):1222–1233PubMedCrossRefGoogle Scholar
  19. 19.
    Yap LB, Turner HE, Adams CB, Wass JA (2002) Undetectable postoperative cortisol does not always predict long-term remission in Cushing’s disease: a single centre audit. Clin Endocrinol (Oxf) 56:25–31CrossRefGoogle Scholar
  20. 20.
    Hammer GD, Tyrrell JB, Lamborn KR, Applebury CB, Hannegan ET, Bell S, Rahl R, Lu A, Wilson CB (2004) Transsphenoidal microsurgery for Cushing’s disease: initial outcome and long-term results. J Clin Endocrinol Metab 89:6348–6357PubMedCrossRefGoogle Scholar
  21. 21.
    Freda PU, Wardlaw SL, Post KD (1998) Long-term endocrinological follow-up evaluation in 115 patients who underwent transsphenoidal surgery for acromegaly. J Neurosurg 89:353–358PubMedCrossRefGoogle Scholar
  22. 22.
    Kreutzer J, Vance ML, Lopes MB, Laws ER Jr (2001) Surgical management of GH-secreting pituitary adenomas: an outcome study using modern remission criteria. J Clin Endocrinol Metab 86:4072–4077PubMedCrossRefGoogle Scholar
  23. 23.
    Nomikos P, Buchfelder M, Fahlbusch R (2005) The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical ‘cure’. Eur J Endocrinol 152:379–387PubMedCrossRefGoogle Scholar
  24. 24.
    Tyrrel JB, Lamborn KR, Hannegan LT, Applebury CB, Wilson CB (1999) Transsphenoidal microsurgical therapy of prolactinomas: initial outcomes and long-term results. Neurosurgery 44(2):254–261; discussion 261–263Google Scholar
  25. 25.
    Ciric I, Ragin A, Baumgartner C, Pierce DB (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature and personal experience. Neurosurgery 40:225–237PubMedCrossRefGoogle Scholar
  26. 26.
    Semple PL, Laws ER Jr (1999) Complications in a contemporary series of patients who underwent transsphenoidal surgery for Cushing’s disease. J Neurosurg 91:175–179PubMedCrossRefGoogle Scholar
  27. 27.
    de Divitiis E, Cappabianca P, Cavallo M (2003) Endoscopic endonasal transsphenoidal approach to the sellar region. In: de Divitiis E, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien, pp 91–130CrossRefGoogle Scholar
  28. 28.
    Shin SS, Tormenti MJ, Paluzzi A, Rothfus WE, Chang YF, Zainah H, Fernandez-Miranda JC, Snyderman CH, Challinor SM, Gardner PA (2012) Endoscopic endonasal approach for growth hormone secreting pituitary adenomas: outcomes in 53 patients using 2010 consensus criteria for remission. Pituitary. (Epub ahead of print)Google Scholar
  29. 29.
    Rivera-Serrano CM, Snyderman CH, Gardner P, Prevedello D, Wheless S, Kassam AB, Carrau RL, Germanwala A, Zanation A (2011) Nasoseptal “rescue” flap: a novel modification of the nasoseptal flap technique for pituitary surgery. Laryngoscope 121(5):990–993. doi: 10.1002/lary.21419 PubMedCrossRefGoogle Scholar
  30. 30.
    Chee GH, Mathias DB, James RA, Kendall-Taylor P (2001) Transsphenoidal pituitary surgery in Cushing’s disease: can we predict outcome? Clin Endocrinol (Oxf) 54(5):617–626Google Scholar
  31. 31.
    Scanlon MF, Peters JR, Thomas JP, Richards SH, Morton WH, Howell S, Williams ED, Hourihan M, Hall R (1985) Management of selected patients with hyperprolactinaemia by partial hypophysectomy. Br Med J (Clin Res Ed) 291(6508):1547–1550Google Scholar
  32. 32.
    Pereira AM, van Aken MO, van Dulken H, Schutte PJ, Biermasz NR, Smit JW, Roelfsema F, Romijn JA (2003) Long-term predictive value of postsurgical cortisol concentrations for cure and risk of recurrence in Cushing’s disease. J Clin Endocrinol Metab 88(12):5858–5864Google Scholar
  33. 33.
    Beauregard C, Truong U, Hardy J, Serri O (2003) Long-term outcome and mortality after transsphenoidal adenomectomy for acromegaly. Clin Endocrinol (Oxf) 58(1):86–91Google Scholar
  34. 34.
    Cho DY, Liau WR (2002) Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg Neurol 58(6):371–375; discussion 375–376Google Scholar
  35. 35.
    Hofmann BM, Fahlbusch R (2006) Treatment of Cushing’s disease: a retrospective clinical study of the latest 100 cases. Front Horm Res 34:158–184Google Scholar
  36. 36.
    Maira G, Anile C, De Marinis L, Barbarino A (1990) Prolactin-secreting adenomas--surgical results. Can J Neurol Sci 17(1):67–70Google Scholar
  37. 37.
    Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40(2):225–236; discussion 236–237Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Alessandro Paluzzi
    • 1
  • Juan C. Fernandez-Miranda
    • 1
  • S. Tonya Stefko
    • 1
    • 2
    • 3
  • Sue Challinor
    • 4
  • Carl H. Snyderman
    • 1
    • 2
  • Paul A. Gardner
    • 1
  1. 1.Department of Neurological Surgery, UPMC Presbyterian HospitalUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Department of OtolaryngologyUniversity of Pittsburgh School of MedicinePittsburghUSA
  3. 3.Department of OphthalmologyUniversity of Pittsburgh School of MedicinePittsburghUSA
  4. 4.Department of Medicine, Division of Endocrinology and MetabolismUniversity of Pittsburgh School of MedicinePittsburghUSA

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