Pituitary adenoma resection is achieved from various approaches, the most common being
microscopic, speculum-based transnasal or sublabial transsphenoidal resection. Rates
of tumor recurrence following this technique range from 30%–40%.
Two-surgeon, purely endoscopic endonasal techniques, with the option of expanded exposure,
offer the potential advantage of increased visibility of the supra- and parasellar
regions, allowing more complete tumor resection, even for cases of recurrent pituitary
tumors. However, the scarring and altered anatomy that result from the previous dissection
make revision surgery a technically challenging endeavor. We review our experience
in a series of patients who underwent revision endoscopic pituitary surgery following
previous microscopic, speculum-based transnasal or sublabial approaches.
Records were reviewed of 151 patients who underwent endoscopic endonasal pituitary
surgery between February 2008 and August 2010. Of these, 26 patients had previous
microscopic-speculum-based approaches. Speculum-based approaches are nearly always
done through the right nostril. As a result, there was increased scarring and loss
of anatomical landmarks in the right posterior nasal cavity and sphenoid region. Our
most frequent form of skull base reconstruction is the nasoseptal flap, elevated from
the right septum. However, in one patient a septal perforation did not allow a nasoseptal
flap elevation. In another patient, the pedicle of the right-sided flap became detached
due to the previous dissection of the right anterior clival wall. Because of the right-sided
posterior nasal scarring encountered, a left-sided nasoseptal flap was successfully
utilized in six patients. Image guidance was used in 22 patients. There were 13 intraoperative
CSF leaks, which were repaired using a combination of techniques. There was only one
delayed CSF leak on postoperative day 23, requiring operative repair with an abdominal
fat graft.
In conclusion, revision endoscopic pituitary surgery following microscopic, speculum-based
approaches is technically challenging. Because the previous approach was likely through
the right nostril, we have found it advantageous to elevate the nasoseptal flap from
the left side. Intraoperative CSF leaks are frequent and should be addressed with
appropriate reconstructive techniques. The use of image guidance should be considered
because of the altered anatomic landmarks.
