Initial Experience with Endoscopic Endonasal Approach for the Treatment of Cushing’s Disease in a Large Tertiary Center in São Paulo, Brazil

Background Patients with Cushing’s disease have morbidity and mortality rates two to five times more than the general population, making its treatment a medical imperative. Pituitary surgery has been the standard treatment for Cushing’s disease. Currently, the endoscopic endonasal approach (EEA) is the most widely used technique for treating this serious medical condition. However, among some endocrinologists and neurosurgeons used to the microscope-assisted technique, there are still questions about the effectiveness and safety of transitioning to the endoscopic endonasal approach.

We aim to show our initial experience with such transition in a large tertiary hospital in São Paulo, Brazil.

Method The medical records patients diagnosed with Cushing’s disease treated between March 2004 and March 2014 who underwent EEA in our center as a first treatment and who had a minimum of 12 months postoperative follow-up were reviewed. The imaging studies, patient and tumor characteristics, complications, remission and recurrence rates, and patients’ comorbidities control were noted and analyzed.

Results Our cohort had 16 patients (14 females and 2 males). The age at diagnosis ranged from 16 to 53 years, with a mean age of 33.7 years. The mean follow-up was 52.0 months, ranging from 15.5 to 94.3 months.

Preoperative magnetic resonance imaging (MRI) of the sella identified an adenoma in 93.8% of the patients (56.2% microadenomas and 37.5% macroadenomas).

Nine patients underwent selective adenomectomy; five underwent total hypophysectomy and two underwent hemihypophysectomy.

Postoperative cerebrospinal fluid leak was observed in two patients (12.5%). Both underwent surgical review with successful closure of the leak. Postoperative epistaxis occurred in 12.5% (two) of patients, who were treated with bedside tamponade without the need for surgical review. No patients presented with new neurological deficits after surgery. Transient diabetes insipidus (DI) was observed in 43.7% of patients and one patient developed permanent DI.

The early remission and sustained remission rates after a single procedure were 87.5 and 68.75%, respectively. Among the patients who had a microadenoma, 77.8% went into sustained remission with a single procedure, while among those with macroadenomas only 50% went into remission with a single procedure.

Weight reduction improved control of blood pressure and lower serum glucose levels were documented in 68.75, 60, and 55.5% of patients, respectively, after remission.

Conclusion Despite the need for specialized training, equipment, and team building by ENT and neurosurgery, the transition from microscope-assisted pituitary surgery to EEA is possible and safe.

The clinical outcomes, even in the early years, are similar to the previous microscope-assisted treatment and, over time, with greater experience and knowledge there is a tendency for improvement.