Skip to main content

Pro: endoscopic endonasal transsphenoidal pituitary surgery is superior to microscope-based transsphenoidal surgery

Abstract

The introduction of the endoscope to transsphenoidal pituitary surgery is relatively new, but represents a major advancement in the field. The use of the endoscope to visualize the sella via a direct endonasal approach offers the surgeon dramatically better visualization as well as improved range of motion compared to the operating microscope. Growing evidence confirms that these improvements directly translate into better surgical resections and outcomes. Further, patient comfort and satisfaction are higher with the endonasal method compared with other transsphenoidal approaches, and it is a cost effective technology. This position paper will outline the reasons that endoscopic endonasal transsphenoidal surgery is the preferred method for pituitary surgery, and why it will likely be adopted as the standard technique for transsphenoidal surgery worldwide.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. G. Lanzino, E.R. Laws, Pioneers in the development of transsphenoidal surgery: Theodor Kocher, Oskar Hirsch, and Norman Dott. J. Neurosurg. 95(6), 1097–1103 (2001)

    PubMed  Article  CAS  Google Scholar 

  2. J.K. Liu, K. Das, M.H. Weiss, E.R. Laws Jr, W.T. Couldwell, The history and evolution of transsphenoidal surgery. J. Neurosurg. 95(6), 1083–1096 (2001)

    PubMed  Article  CAS  Google Scholar 

  3. A.A. Cohen-Gadol, E.R. Laws, D.D. Spencer, A.A. De Salles, The evolution of Harvey Cushing’s surgical approach to pituitary tumors from transsphenoidal to transfrontal. J. Neurosurg. 103(2), 372–377 (2005)

    PubMed  Article  Google Scholar 

  4. A.S. Kanter, A.S. Dumont, A.R. Asthagiri, R.J. Oskouian, J.A. Jane Jr, E.R. Laws Jr, The transsphenoidal approach. A historical perspective. Neurosurg. Focus 18(4), e6 (2005)

    PubMed  Google Scholar 

  5. G. Lanzino, E.R. Laws, Key personalities in the development and popularization of the transsphenoidal approach to pituitary tumors: an historical overview. Neurosurg. Clin. N. Am. 14(1), 1–10 (2003)

    PubMed  Article  Google Scholar 

  6. W.R. Spencer, K. Das, C. Nwagu, E. Wenk, S.D. Schaefer, A. Moscatello, W.T. Couldwell, Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope. Laryngoscope 109(5), 791–794 (1999)

    PubMed  Article  CAS  Google Scholar 

  7. P. Cappabianca, L.M. Cavallo, O. de Divitiis, D. Solari, F. Esposito, A. Colao, Endoscopic pituitary surgery. Pituitary 11(4), 385–390 (2008)

    PubMed  Article  Google Scholar 

  8. R.X. Cheng, H.L. Tian, W.W. Gao, Z.Q. Li, A comparison between endoscopic trans-sphenoidal surgery and traditional trans-sphenoidal microsurgery for functioning pituitary adenomas. J. Int. Med. Res. 39(5), 1985–1993 (2011)

    PubMed  Article  Google Scholar 

  9. D.Y. Cho, W.R. Liau, Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas. Surg. Neurol. 58(6), 371–375 (2002); discussion 375–376

    PubMed  Article  Google Scholar 

  10. C.P. Hofstetter, R.H. Mannaa, L. Mubita, V.K. Anand, J.W. Kennedy, A.R. Dehdashti, T.H. Schwartz, Endoscopic endonasal transsphenoidal surgery for growth hormone-secreting pituitary adenomas. Neurosurg. Focus 29(4), E6 (2010)

    PubMed  Article  Google Scholar 

  11. J.A. Jane, R.M. Starke, M.A. Elzoghby, D.L. Reames, S.C. Payne, M.O. Thorner, J.C. Marshall, E.R. Laws Jr, M.L. Vance, Endoscopic transsphenoidal surgery for acromegaly: remission using modern criteria, complications, and predictors of outcome. J. Clin. Endocrinol. Metab. 96(9), 2732–2740 (2011)

    PubMed  Article  CAS  Google Scholar 

  12. A.N. Mamelak, J. Carmichael, V.H. Bonert, O. Cooper, S. Melmed, Single-surgeon fully endoscopic endonasal transsphenoidal surgery: outcomes in three-hundred consecutive cases. Pituitary 16(3), 393–401 (2013)

    PubMed  Article  Google Scholar 

  13. M.A. Wagenmakers, R.T. Netea-Maier, E.J. van Lindert, G.F. Pieters, A.J. Grotenhuis, A.R. Hermus, Results of endoscopic transsphenoidal pituitary surgery in 40 patients with a growth hormone-secreting macroadenoma. Acta Neurochir. (Wien) 153(7), 91–99 (2011)

    Article  Google Scholar 

  14. A.R. Dehdashti, A. Ganna, K. Karabatsou, F. Gentili, Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 62(5), 1006–1015 (2008); discussion 1015–1007

    PubMed  Article  Google Scholar 

  15. K.D. Nielson, C. Watts, K. Clark, Transsphenoidal microsurgery for selective removal of functional pituitary microadenomas. World J. Surg. 1(1), 79–84 (1977)

    PubMed  Article  CAS  Google Scholar 

  16. M. Powell, Microscope and endoscopic pituitary surgery. Acta Neurochir. (Wien) 151(7), 723–728 (2009)

    Article  Google Scholar 

  17. A. Rudnik, B. Kos-Kudła, D. Larysz, T. Zawadzki, P. Bazowski, Endoscopic transsphenoidal treatment of hormonally active pituitary adenomas. Neuro Endocrinol. Lett. 28(4), 438–444 (2007)

    PubMed  Google Scholar 

  18. R.M. Starke, D.L. Reames, C.J. Chen, E.R. Laws, J.A. Jane Jr, Endoscopic transsphenoidal surgery for cushing disease: techniques, outcomes, and predictors of remission. Neurosurgery 72(2), 240–247 (2013); discussion 247

    PubMed  Article  Google Scholar 

  19. R.M. Starke, D.M. Raper, S.C. Payne, M.L. Vance, E.H. Oldfield, J.A. Jane Jr, Endoscopic vs microsurgical transsphenoidal surgery for acromegaly: outcomes in a concurrent series of patients using modern criteria for remission. J. Clin. Endocrinol. Metab. 98(8), 3190–3198 (2013)

    PubMed  Article  CAS  Google Scholar 

  20. H.L. Storr, W.M. Drake, J. Evanson, M. Matson, D.M. Berney, A.B. Grossman, S.A. Akker, J.P. Monson, G. Alusi, M.O. Savage, I. Sabin, Endonasal endoscopic transsphenoidal pituitary surgery: early experience and outcome in paediatric Cushing’s disease. Clin. Endocrinol. (Oxf) 80(2), 270–276 (2014)

    Article  Google Scholar 

  21. A. Tabaee, V.K. Anand, Y. Barrón, D.H. Hiltzik, S.M. Brown, A. Kacker, M. Mazumdar, T.H. Schwartz, Endoscopic pituitary surgery: a systematic review and meta-analysis. J. Neurosurg. 111(3), 545–554 (2009)

    PubMed  Article  Google Scholar 

  22. R.J. Oskouian, D.F. Kelly, E.R. Laws Jr, Vascular injury and transsphenoidal surgery. Front Horm. Res. 34, 256–278 (2006)

    PubMed  Article  Google Scholar 

  23. M. Berker, D.B. Hazer, T. Yücel, A. Gürlek, A. Cila, M. Aldur, M. Onerci, Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary 15(3), 288–300 (2012)

    PubMed  Article  Google Scholar 

  24. P. Charalampaki, A. Ayyad, R.A. Kockro, A. Perneczky, Surgical complications after endoscopic transsphenoidal pituitary surgery. J. Clin. Neurosci. 16(6), 786–789 (2009)

    PubMed  Article  Google Scholar 

  25. J.R. Dusick, F. Esposito, D. Malkasian, D.F. Kelly, Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 60(4 Suppl 2), 322–328 (2007); discussion 328–329

    PubMed  Google Scholar 

  26. N. Fatemi, J.R. Dusick, M.A. De Paiva Neto, D.F. Kelly, The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 63(4 Suppl 2), 244–256 (2008); discussion 256

    PubMed  Article  Google Scholar 

  27. A.B. Kassam, D.M. Prevedello, R.L. Carrau, C.H. Snyderman, A. Thomas, P. Gardner, A. Zanation, B. Duz, S.T. Stefko, K. Byers, M.B. Horowitz, Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J. Neurosurg. 114(6), 1544–1568 (2011)

    PubMed  Article  Google Scholar 

  28. E.R. Laws, Vascular complications of transsphenoidal surgery. Pituitary 2(2), 163–170 (1999)

    PubMed  Article  Google Scholar 

  29. H. Raja, T. Upile, W. Jerjes, N. Charakias, V. Dewan, R.M. Redfern, Microscopic endonasal access in pituitary surgery for tumour removal: eight-year review of nasal complications. Head Neck Oncol. 4, 76 (2012)

    Google Scholar 

  30. J.K. Goudakos, K.D. Markou, C. Georgalas, Endoscopic versus microscopic trans-sphenoidal pituitary surgery: a systematic review and meta-analysis. Clin. Otolaryngol. 36(3), 212–220 (2011)

    PubMed  Article  CAS  Google Scholar 

  31. M. Ammirati, L. Wei, I. Ciric, Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis. J. Neurol. Neurosurg. Psychiatry 84(8), 843–849 (2013)

    PubMed  Article  PubMed Central  Google Scholar 

  32. B.Y. Kim, H.L. Son, S.G. Kang, S.W. Kim, Y.K. Hong, S.S. Jeun, S.W. Kim, J.H. Cho, Y.J. Park, Postoperative nasal symptoms associated with an endoscopic endonasal transsphenoidal approach. Eur. Arch. Otorhinolaryngol. 270(4), 1355–1359 (2013)

    PubMed  Article  Google Scholar 

  33. I. Koren, T. Hadar, Z.H. Rappaport, E. Yaniv, Endoscopic transnasal transsphenoidal microsurgery versus the sublabial approach for the treatment of pituitary tumors: endonasal complications. Laryngoscope 109(11), 1838–1840 (1999)

    PubMed  Article  CAS  Google Scholar 

  34. J. Strychowsky, S. Nayan, K. Reddy, F. Farrokhyar, D. Sommer, Purely endoscopic transsphenoidal surgery versus traditional microsurgery for resection of pituitary adenomas: systematic review. J. Otolaryngol. Head Neck Surg. 40(2), 175–185 (2011)

    PubMed  Google Scholar 

  35. A. Colao, M. Boscaro, D. Ferone, F.F. Casanueva, Managing Cushing’s disease: the state of the art. Endocrine (2014). doi:10.1007/s12020-013-0129-2

    Google Scholar 

  36. P. Leach, A.H. Abou-Zeid, T. Kearney, J. Davis, P.J. Trainer, K.K. Gnanalingham, Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve. Neurosurgery 67(5), 1205–1212 (2010)

    PubMed  Article  Google Scholar 

  37. Z. Zador, K. Gnanalingham, Endoscopic transnasal approach to the pituitary–operative technique and nuances. Br. J. Neurosurg. 27(6), 718–726 (2013)

    PubMed  Article  Google Scholar 

  38. J.R. Dusick, F. Esposito, C.A. Mattozo, C. Chaloner, D.L. McArthur, D.F. Kelly, Endonasal transsphenoidal surgery: the patient’s perspective-survey results from 259 patients. Surg. Neurol. 65(4), 332–341 (2006); discussion 341–332

    PubMed  Article  Google Scholar 

  39. G. Zada, D.F. Kelly, P. Cohan, C. Wang, R. Swerdloff, Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions. J. Neurosurg. 98(2), 350–358 (2003)

    PubMed  Article  Google Scholar 

  40. J.A. Gondim, J.P. Almeida, L.A. Albuquerque, M. Schops, E. Gomes, T. Ferraz, W. Sobreira, M.T. Kretzmann, Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 14(2), 174–183 (2011)

    PubMed  Article  Google Scholar 

  41. G. Kahilogullari, S. Beton, E.S. Al-Beyati, O. Kantarcioglu, M. Bozkurt, E. Kantarcioglu, A. Comert, M.A. Unlu, C. Meco, Olfactory functions after transsphenoidal pituitary surgery: endoscopic versus microscopic approach. Laryngoscope 123(9), 2112–2119 (2013)

    PubMed  Article  Google Scholar 

  42. S. Lwu, I. Edem, B. Banton, M. Bernstein, A. Vescan, F. Gentili, G. Zadeh, Quality of life after transsphenoidal pituitary surgery: a qualitative study. Acta Neurochir. (Wien) 154(10), 1917–1922 (2012)

    Article  Google Scholar 

  43. N. McLaughlin, A.A. Eisenberg, P. Cohan, C.B. Chaloner, D.F. Kelly, Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery. J. Neurosurg. 118(3), 613–620 (2013)

    PubMed  Article  Google Scholar 

  44. I. Ciric, S. Rosenblatt, J.C. Zhao, Transsphenoidal microsurgery. Neurosurgery 51(1), 161–169 (2002)

    PubMed  Article  Google Scholar 

  45. A.C. Chan, S.C. Chung, A.P. Yim, J.Y. Lau, E.K. Ng, A.K. Li, Comparison of two-dimensional vs three-dimensional camera systems in laparoscopic surgery. Surg, Endosc. 11(5), 438–440 (1997)

    Article  CAS  Google Scholar 

  46. A.N. Mamelak, t Nobuto, G. Berci, Initial clinical experience with a high-definition exoscope system for microneurosurgery. Neurosurgery 67(2), 476–483 (2010)

    PubMed  Article  Google Scholar 

  47. A.N. Mamelak, D. Drazin, A. Shirzadi, K.L. Black, G. Berci, Infratentorial supracerebellar resection of a pineal tumor using a high definition video exoscope (VITOM®). J. Clin. Neurosci. 19(2), 306–309 (2012)

    PubMed  Article  Google Scholar 

  48. E. Kari, N.M. Oyesiku, V. Dadashev, S.K. Wise, Comparison of traditional 2-dimensional endoscopic pituitary surgery with new 3-dimensional endoscopic technology: intraoperative and early postoperative factors. Int. Forum Allergy Rhinol. 2(1), 2–8 (2012)

    PubMed  Article  Google Scholar 

  49. I. Yang, M.B. Wang, M. Bergsneider, Making the transition from microsurgery to endoscopic trans-sphenoidal pituitary neurosurgery. Neurosurg. Clin. N. Am. 21(4), 643–651 (2010)

    PubMed  Article  Google Scholar 

Download references

Acknowledgments

The author would like to thank Vivien Bonert, MD, Odelia Cooper, MD and Anat BenShlomo MD for their constructive comments.

Conflict of interest

The author declares he has no conflicts of interests. He has previously (2011) served as a paid consultant to Karl Storz Endoscopy, but at present has no such relationships.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Adam N. Mamelak.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Mamelak, A.N. Pro: endoscopic endonasal transsphenoidal pituitary surgery is superior to microscope-based transsphenoidal surgery. Endocrine 47, 409–414 (2014). https://doi.org/10.1007/s12020-014-0294-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12020-014-0294-y

Keywords

  • Pituitary
  • Transsphenoidal
  • Surgery
  • Endoscopy
  • Microscope