The microscopic transnasal tumor surgery (TNTS) has stood the test of time since its
inception in 1960; however, the advent of the endoscopic nasal pituitary surgery (EPS)
has made inroads in this particular field with its myriad benefits. Both TNTS and
EPS procedures are effective tools in tackling pituitary tumors.[1] The ardent supporters of TNTS promote the benefits of maintaining stereoscopic vision,
instrument mobility, control of bleeding effectively, retraction of the edematous
nasal tissues, and quick access to the sella. On the other hand, the transition to
the EPS procedure is happening worldwide, clearly on account of its advantages, which
include a wide panoramic view, improved illumination, ability to look around the anatomical
corners using an angled tip, and extended approach to the paraseller tumors.[1] Instrumental maneuverability during the endoscopic procedures has been alleviated
with the introduction of newer endoscopic specific instruments, and high-definition
3D endoscopic system may resolve issues pertaining to stereoscopic resolution.
Meta-analyses reveal a clear advantage of EPS over the TNTS procedure in relation
to the locally invasive tumor with parasellar extension; its benefits also include
more effective resection and good endocrinological outcome.[2]
[3] For tumors invading the cavernous sinus, higher resection rates have been observed,
with the endoscope depicting a clear advantage of the panoramic and the angled views
of the cavernous sinus medial wall.[4]
[5] EPS is considered a valid option in treating recurrent forms of adenoma. Wide exposure
of the sella is especially ensured, keeping in mind the limited exposure of the previous
microscopic surgical procedures, which was responsible for incomplete tumor resection.
Nasal morbidities such as sinusitis, anosmia, epistaxis, nasal congestion, and septal
perforation are comparatively lesser in amount in the endoscopic nasal surgery.[1] A comfortable postoperative course is provided by way of the following:
-
Lesser mucosal detachment
-
Absence of sub-labial incision
-
Absence of routine nasal packing
These result in the reduction of the postoperative pain and ensure a quick recovery
and short hospital stay.[1]
Despite the wider exposure and dissection, and the attendant higher risk of the intra-operative
CSF leak, the incidence of the postoperative leak in the EPS is equivalent to the
microscopic surgery in the recent literature.[1] The risk of permanent diabetes insipidus is between 0.7 and 8.5%.[6] Injury to the carotid artery is a rare but potentially life-threatening complication.[7] Thus, in general, the surgical complication rate of the endoscopic approach is equal
to that of the microscopic approach. Endoscopic nasal surgery is cost effective in
comparison to its microscopic counterpart. The learning curve may deter some microscopically
trained neurosurgeons from embracing the endoscopic approach, because of an unwillingness
on their part to accept the complications during the procedure. This can be overcome
by attending workshops concerning endoscopic nasal and paranasal anatomy, endoscopic
surgery, and then gradually moving from endoscopic-assisted microscopic procedure
to pure EPS. In the initial cases, proper case selection, operative planning, instrumentation
with assistance from a surgeon well-versed with the technique would help to make a
tangible difference. Also, an attitude in favor of converting EPS to TNTS immediately
in case of difficulty would be a good approach to avert any complication.
Endoscopic nasal pituitary surgery with its innovative techniques such as 3D endoscopic
system, endoscopic augmented reality navigation system, and ultrasonography-assisted
endoscope have increased the safety and revolutionized the concept of pituitary surgeries
in developed countries.[1] Despite their relative absence in our part of the world, the results are extremely
encouraging.
The EPS is definitely going to replace TNTS, and it is only the time that will decide
when, as a famous quote from Steve Jobs says,
“The over-all point is that new technology will not necessarily replace old technology,
but it will date it. By definition. Eventually, it will replace it. But it is like
people who had black-and-white TVs when color came out. They eventually decided whether
or not the new technology was worth the investment.”
