Transition from the Traditional Microscopic to the Endoscopic Endonasal Approach for Resection Skull Base Lesions: Initial Experience, Limitations and Barriers in a Middle-Income Country

Introduction: The access to image-guided skull base surgery and the rapidly growing training on minimally invasive endoscopic techniques in North America through research fellowships has allowed surgeons from low-to-middle income countries (LMICs) to perform endoscopic procedures in their home countries.

Object: The aim of this study was to investigate the limitations, barriers, and complications in a 3-year transition period from the endonasal microscopic approach to the endonasal endoscopic approach (EEA) to the skull base in our institution.

Methods: This is a retrospective observational study of a prospective cohort of patients >18 years of age who underwent first transsphenoidal resection of skull base lesions.

Results: Eighteen patients underwent EEA, 11 underwent microscopic approach, and 5 underwent a mixed endonasal and microscopic approach. Thirty-two cases were pituitary adenomas and two cases were selar arachnoid cysts. In the EEA group one patient presented postoperative hematoma, one patient postoperative cerebrospinal fluid leaking. Endocrine outcomes were similar in the three groups. Patients where visual function remained unchanged or improved were higher on the EEA group (p < 0.05). The time between diagnosis and surgical treatment was higher in the EEA group due to a delayed approval of the procedure from the insurance company (p < 0.05). Combination of microscopic approach and EEA was performed due to the lack of confidence of the surgeon to achieve a maximal safe resection. Costs were higher for the EEA group due to surgical equipment renting, particularly the neuronavigation system, which was not used for the microscopic cases. The period of time from the learning curve was 1.5 years until the EEA protocol was used in a routine fashion by all senior surgeons.

Conclusion: Transition from the microscopic to the endoscopic approach improved visual outcomes, with few additional complications for resection of skull base lesions. Primary limitations and barriers were the lack of confidence of surgeons with the endoscope for a maximal safe resection and the increased costs for the EEA. Further, multicentric studies with a higher number of patients would demonstrate the big picture of the behavior of the surgical curve and the impact of education on endoscopic techniques in LMICs.

Publication History

Article published online:
12 February 2021