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Functional outcome and postoperative complications after the microsurgical removal of large vestibular schwannomas via the retrosigmoid approach: a meta-analysis

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Abstract

For large (≥30 mm) or giant (≥40 mm) vestibular schwannomas (VSs) for which microsurgical removal is the main treatment option, complete tumour resection and the preservation of acceptable facial nerve function can be safely and successfully achieved via the retrosigmoid approach. We performed a meta-analysis to provide a reliable estimate of functional outcome and postoperative complications for patients treated surgically for large VSs. We conducted a comprehensive search in Pubmed, Embase and the Chinese National Knowledge Infrastructure (CNKI) databases to identify publications that included only patients in whom the VSs were >3.0 cm in maximal diameter and microsurgically removed by a retrosigmoid approach. Pooled estimates of proportions with corresponding 95 % confidence intervals were calculated using the Freeman–Tukey double arcsine transformation. This meta-analysis revealed that the pooled proportion of gross total resections was 79.1 % (95 % CI, 64.2–90.8 %; I 2 = 95.4 %). By combining microsurgical techniques with continuous electrophysiological monitoring, the anatomical preservation of the facial nerve at the end of surgery was achieved in 88.8 % (95 % CI, 83.6–93.2 %; I 2 = 76.1 %) of the patients. The pooled proportion of good postoperative facial nerve function (House–Brackmann (HB) grades I–II) was 62.9 % (95 % CI, 50.0–74.9 %; I 2 = 91.1 %). Cerebrospinal fluid leakage was reported in 7.8 % (95 % CI, 4.8–11.4 %; I 2 = 49.8 %) of the patients. The mortality rate was 0.87 % (95 % CI, 0.22–1.78 %; I 2 = 4.9 %). Our meta-analysis revealed that for large VSs, very favourable results can be obtained using the retrosigmoid approach with minimal mortality, especially with respect to anatomical and functional facial nerve preservation.

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Acknowledgments

We thank Prof. Aihua Gu and Dr. Guixiang Ji in the School of Public Health of Nanjing Medical University for statistical analysis. This work is supported by the National Natural Science Foundation of China (grant 30901534), the Jiangsu Province’s Natural Science Foundation (proj. no. BK2009444), the Grant for the 135 Key Medical Project of Jiangsu Province (no. XK201117), and the Priority Academic Program Development of Jiangsu Higher Education Institutions.

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Authors and Affiliations

  1. Department of neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China

    Peng Zou, Lin Zhao, Ping Chen, Haitao Xu, Ning Liu, Peng Zhao & Ailin Lu

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  1. Peng Zou
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  2. Lin Zhao
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  3. Ping Chen
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  4. Haitao Xu
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  6. Peng Zhao
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Correspondence to Peng Zhao or Ailin Lu.

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Comments

M. Samii, V. Gerganov, Hannover, Germany

Modern vestibular schwannoma (VS) surgery is safe and potentially curable. In the case of large or giant tumours, surgery is the only treatment option, and in experienced hands, it is related to very good general and functional outcome, as presented explicitly in the current meta-analysis. Excellent results can be achieved both with the retrosigmoid and the translabyrinthine approaches. The controversy over the superiority of a surgical route belongs to the history of VS surgery. The important points are that the surgeon should be most familiar with the operative technique and should have at his disposal a sufficient number of cases.

Focus of this study is the possibility to achieve a high rate of facial nerve preservation with the retrosigmoid approach. However, the main advantage of this approach, as compared to the translabyrinthine one, is that it allows for hearing preservation. From our experience as well as from published data, it is well-known that preservation of functional hearing is possible even in large and giant VS [1, 3]. Moreover, the retrosigmoid route is associated with a low rate of approach-related morbidity, such as injury to venous structures, parenchymal damage, CSF leak or postoperative headache. We were able to substantially reduce the risk of CSF leak by using pieces of subcutaneous fat tissue for sealing the opened air cells; thus, the rate in our hands is now less than 2.5 %. VS surgery is an extremely demanding procedure and requires a vast experience to achieve an optimal outcome [2]. This fact, along with numerous ethical issues, hinders the idea of multi-centre randomised trials proposed by the authors.

References

1. Di Maio S, Malebranche AD, Westerberg B, Akagami R (2010) Hearing preservation after microsurgical resection of large vestibular schwannomas. Neurosurgery 68 (3):632–640; discussion 640. doi:10.1227/NEU.0b013e31820777b1

2. Samii M, Gerganov V, Samii A (2006) Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients. J Neurosurg 105 (4):527–535. doi:10.3171/jns.2006.105.4.527

3. Samii M, Gerganov VM, Samii A (2009) Functional outcome after complete surgical removal of giant vestibular schwannomas. J Neurosurg 112 (4):860–867. doi:10.3171/2009.7.JNS0989

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Zou, P., Zhao, L., Chen, P. et al. Functional outcome and postoperative complications after the microsurgical removal of large vestibular schwannomas via the retrosigmoid approach: a meta-analysis. Neurosurg Rev 37, 15–21 (2014). https://doi.org/10.1007/s10143-013-0485-7

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