Minimizing Intraoperative CSF Leaks in Endonasal Endoscopic Transsphenoidal Pituitary Surgery: Technical Considerations and Case Series Review

Objective: Endonasal endoscopic transsphenoidal surgery (ETSS) has become a widely accepted technique for management of pituitary and associated skull base tumors since our first description in 1996. Several reconstructive options to repair skull base defects have been described in the literature to minimize the risk of postoperative cerebrospinal fluid (CSF) leak. However, another important technical consideration involves the dissection around the arachnoid membrane to minimize the risk of an intraoperative CSF leak altogether. The objective of this paper is to specifically describe our steps in ETSS to minimize the risk of an intraoperative CSF leak and to present a series of patients who underwent with this technique. A review of the literature is also provided.

Methods: This was a retrospective review of a consecutive series of patients undergoing endonasal transsphenoidal surgery for suspected pituitary tumors between January 2009 and August 2011 at St. Michael's Hospital, Toronto, Canada. All patients underwent the same surgical technique for approach and tumor removal. We routinely employ a nasoseptal flap for reconstruction (unless the flap is unavailable). Patient demographics, intraoperative findings, and postoperative outcomes were recorded.

Results: A total of 88 patients (46 women, 42 men) were included in this review. The mean age was 48.6 ± 16.2 years (range, 16–83 years). The majority of tumors were macroadenomas (76 patients, 86.4%), and 11 cases (12.5%) had a history of previous pituitary surgery. Intraoperative CSF leak occurred in only 16 patients (18.2%) and was transient in 8 and persistent in 8. Only eight patients required duraplasty or fat graft. None of these 16 patients developed a postoperative CSF leak. The overall postoperative CSF leak rate for the 88 patients was 1.1% (1 patient). This patient required a second surgery for repair. No meningitis was observed.

Conclusion: Endonasal transsphenoidal pituitary surgery can be performed with a low risk of a postoperative CSF leak. However, this risk may be further minimized by decreasing the rate of an intraoperative CSF leak during tumor dissection and being meticulous with the skull base reconstruction.