J Neurol Surg B Skull Base 2016; 77 - P113
DOI: 10.1055/s-0036-1580059

Beyond the Endonasal Route: Combined Approaches to Pituitary Adenomas

Jordina Rincon-Torroella 1, Monirah Albathi 2, Kofi D Boahene 2, Alfredo Quinones-Hinojosa 1
  • 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
  • 2Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States

Objective: To evaluate factors influencing the decision to combine endoscopic approaches with open approaches for the resection of pituitary adenomas, and to discuss reconstructive considerations when selecting the combined approach.

Study Design: Retrospective Case Series and Technical Note.

Methods: Between 2005 and 2015, from a cohort of 423 patents, eight consecutive patients underwent a combination of endoscopic, transfacial or transcranial skull base surgery at the Johns Hopkins Hospital. Variables including lesion size, location, extension, and method of resection were analyzed. Outcome data including achievement of surgical goal, hospital stay, complications, reconstructive techniques, and need for subsequent surgery and long-term survival were evaluated through retrospective chart review.

Approach Considerations Preoperative CT and MRI helped estimate tumor size and determine the extent of invasions. Tumor location, extension, and invasion were taken into account when selecting the appropriate approach. The goal was to achieve complete resection in all patients, while ensuring appropriate closure of the cranial base defect.

Results: Six patients had preoperative visual deficits objectivized per visual test field, 4 patients had preoperative endocrine deficits, 2 patients presented with a CSF leak, 6 patients had a primary diagnoses for a pituitary adenoma, 2 patients had a CSF leak after a previous pituitary adenoma removal. The average tumor size was 4.52 cm. All the primary tumors, except for two, presented with cavernous sinus invasion. Three patients underwent a supraorbital craniotomy with a transpalpebral incision combined with an endoscopic endonasal transellar and transplanum approach (EEA). Three patients had a combination of the EEA and the orbitozygomatic approach. On patient required a combined pterional and EEA approach and one patient a combined transmaxillary and EEA with a sublabial incision. Reconstruction was achieved with fascia lata in 2 cases, fat grafts in 3 cases, pericranial flap in 2 cases, and nasoseptal flaps in 1 case. There were no recurrences except for one patient who had 6 previous surgeries. (Table 1)

Conclusion: The majority of pituitary adenomas are amenable to exclusively endoscopic skull base approaches. A small subset of selected macroadenomas necessitate combining more than one approach to successfully remove the tumor and repair the skull base defect.

Fig. 1