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Endoscopic Pituitary/Extended Transphenoidal Tumour Resection

What is an Endoscopic Pituitary/Extended Transsphenoidal Tumor Resection?

An endoscopic pituitary/extended transsphenoidal tumour resection is a minimally invasive surgical procedure in which an endoscope, a thin tubular instrument with a camera, light, and a magnifying lens attached at the end, and special instruments are passed through the nose to surgically remove pituitary tumours from the pituitary gland and skull base. Transsphenoidal refers to approaching the treatment area through the sphenoid sinus - a hollow area in the skull behind the nasal passages and beneath the brain. The wall behind the sinus covers the pituitary gland.

The pituitary gland is a small gland with 2 lobes located near the base of the brain behind the sphenoid sinus of the nose. It manufactures vital hormones necessary for bodily functions.

Pituitary tumours are abnormal growths within the pituitary gland. They can cause hormonal issues and vision problems. Resection of these tumours often restores normal hormone balance and reverses vision issues.

Indications for Endoscopic Pituitary/Extended Transsphenoidal Tumor Resection

Endoscopic pituitary/extended transsphenoidal tumour resection is indicated for treating the following conditions:

  • Pituitary adenoma - a benign (noncancerous) tumour that develops in the pituitary gland
  • Meningioma – a tumour that develops from the meninges or dura mater (membrane that covers the brain and spinal cord)
  • Chordoma - a malignant (cancerous) bone tumour that develops from the base of the skull
  • Rathke’s cleft cyst – a fluid-filled sac that develops between the 2 lobes of the pituitary gland 
  • Craniopharyngioma - a benign tumour that develops from cells close to the pituitary stalk

Preparation for Endoscopic Pituitary/Extended Transsphenoidal Tumor Resection

Presurgical preparation for endoscopic pituitary/extended transsphenoidal tumour resection involves the following steps:

  • A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
  • Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
  • You will be asked if you have allergies to medications, anaesthesia, or latex.
  • You should inform your doctor of any medications, vitamins, or supplements that you are taking.
  • You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
  • You should refrain from tobacco at least a week before and two weeks after surgery.
  • You should not consume any solids or liquids at least 8 hours prior to surgery.
  • Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
  • Written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Endoscopic Pituitary/Extended Transsphenoidal Tumor Resection

Endoscopic pituitary/extended transsphenoidal tumour resection is mostly performed under fluoroscopic guidance (live x-ray imaging) and takes about 2 to 3 hours to complete. In general, the procedure involves the following steps:

  • You will be placed on the operating table in a face-up position and administered general anaesthesia.
  • An image guidance system may be positioned on your head to help your surgeon navigate via either of your nostrils using 3-D mapping.
  • Your surgeon inserts an endoscope in one of your nostrils and advances to the back of the nasal cavity.
  • The endoscope is connected to an external monitor, which enables your surgeon to visualise the surrounding structures on the monitor.
  • Your surgeon passes surgical instruments through the endoscope while looking at the monitor and a bony opening is made in the nasal septum and sphenoid sinus to access the sella, a thin bone covering the pituitary gland.
  • A small opening is made on the sella to expose the strong lining of the skull known as the dura. The dura is then cut open to expose the tumour and pituitary gland.
  • Through the sellar opening, your surgeon removes all tumour tissue using long grasping instruments.
  • After confirming complete removal of the tumour, the scope and instruments are withdrawn and the hole in the sella floor is packed with a bone graft to complete the operation.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after endoscopic pituitary/extended transsphenoidal tumour resection will involve the following steps:

  • You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions and monitor your vital signs.
  • The day after the surgery an endocrinologist may visit you to ascertain that the pituitary gland is functioning normally.
  • Most patients may need to stay in the hospital for a day or two before being discharged. 
  • You may experience pain, headache, nasal congestion, and nausea. Medications are prescribed as needed to address these issues.
  • Antibiotics are prescribed as needed to address the risk of surgery-related infection.
  • Your diet is gradually reintroduced following surgery. You will start with clear liquids, then progress to having normal solid foods, as tolerated.
  • Instructions on surgical site care and bathing will be provided.
  • Refrain from smoking for the period of time specified by your doctor, as this can negatively impact the healing process.
  • Refrain from strenuous activities and lifting anything heavier than 5 pounds for at least a month. Gradual increase in activities over a period of time is recommended.
  • Walking is a good starting point for exercise, and regular walking is recommended to improve strength and endurance.
  • Refrain from driving for a couple of weeks or until you are fully fit and receive your doctor’s consent.
  • A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Endoscopic pituitary/extended transsphenoidal tumour resection is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

  • Infection
  • Bleeding
  • Blood clots or deep vein thrombosis (DVT)
  • Anaesthetic/allergic reactions
  • Nerve damage
  • cerebrospinal fluid (CSF) leakage
  • Sinus congestion
  • Nasal deformity
  • Stroke
  • Vision loss
  • Damage to the pituitary gland
  • King's College London
  • Stanford University
  • University of Pittsburgh Medical Center
  • The Royal College of Surgeons of England