gms | German Medical Science

Objective: The direct endonasal endoscopic approach is currently under investigation for perisellar tumour surgery. A higher resection rate is to be expected and nasal complications should be minimized. However, the reported results with this technique are diverging. Here, the authors report their technique of transnasal endoscopic neurosurgery after 169 procedures.

Methods: Between October 2000 and October 2006, 164 patients (81 males, 83 females, mean age 58 yrs [range 23-83 yrs]) underwent 169 endoscopic endonasal transsphenoidal procedures for perisellar lesions. All patients were prospectively followed. Procedures were video recorded. The surgical technique was carefully analyzed. Special attention was paid to the application of various optics, the necessity of switching to the microscope, complications, surgical radicality, symptom relief and postsurgical nasal complaints.

Results: Lesions consisted of 124 endocrine inactive macroadenomas, 19 acromegaly lesions, 6 Rathke's cleft cysts, 6 prolactinomas, 3 Cushing diseases, 4 clivus chordomas, one mucocele and one fronto-basal encephalocele. In all cases was a nasal speculum used. All procedures were performed with the 0° optics. 30° and 45° optics were used for the assessment of radicality. In two cases (1.1%), conversion to microsurgery was required for recurrent bleeding. Visual deficits were the presenting symptom in 138 cases (84%). Hormonal activity was the leading symptom in 18 cases (10.8%). Mean surgical time scored 108 min (range 57 - 220 min). In 116 of the 164 patients (71%), radical tumor resection was intended at surgery. At follow-up (2 weeks to 4 years; mean 1.84 years), MRI revealed radical tumour resection in 105 cases when intended (91%). Preoperative visual deficits improved in 121 (88%), a worsening was recorded in one 55-year-old woman (0.6%). Recurrent tumour growth was observed in 5 younger patients (3%) and subsequent surgery was required. There was no mortality. There were 2 cases of meningitis (1.2%) and 4 cases of CSF leakage (2.4%). Two patients (1.2%) complained of severe postoperative nasal congestion or reduced nasal air flow.

Conclusions: All in all, the authors consider the transnasal approach with use of a nasal speculum and an endoscope as the technique of choice for perisellar tumours. The technique has been shown to be safe and successful with a high radicality and only minor complications. In contrast to microsurgery, the various endoscopes allow a look “around the corner” for safe radical tumour removal. In contrast to the nasolabial approach, only minimal nasal complaints were reported.