Endoscopic trans-sphenoidal pituitary surgery: is it here to stay?

Trans-sphenoidal surgery for pituitary tumours celebrates the centenary of the first operation by Schloffer in Austria. Despite suffering the disadvantage of being abandoned by Cushing, the procedure survived and over the last 30 years has become the accepted first choice surgical route for these tumours. The fascinating story of Cushing’s pupil, Norman Dott, teaching the method to Guiot of Paris and Guiot to Hardy of Montreal, who in turn introduced the refinements of the operating microscope, will be known to most neurosurgeons. At the start of the twenty-first century, not only do we have a number of safe modifications of the original technique to choose from, we have other refinements, such as frameless neuronavigation, to make the procedure safer, especially for re-operations and for extended trans-sphenoidal approaches. More importantly, we have a clearer idea of what to expect in terms of outcome. We now know that surgical outcomes for functioning pituitary adenomas are dependant on the surgical expertise and, in expert hands, the cure rate rates for acromegaly and Cushing’s disease range from 50 to 85%. Unfortunately, when the inexperienced surgeon operates, the results are likely to be poor, emphasizing the need for specialist pituitary surgeons. For those patients presenting with visual loss from macroadenomas causing chiasmal compression, trans-sphenoidal surgery improves vision in about 70 – 95% of patients in most series. Although it was never said as such, even the relatively inexperienced surgeon should get good outcomes, with respect to visual recovery. Complication rates following trans-sphenoidal surgery are also known, again demonstrating the overall safety of the procedure even in relatively inexperienced hands. So microscopic trans-sphenoidal surgery has good expected outcomes with low morbidity and mortality, and short in-patient stays—an ideal situation in the twenty-first century. Consequently, any new surgical developments in pituitary surgery would have to carry significant benefits to make it worthwhile. Endoscopic trans-sphenoidal pituitary surgery presents such a challenge. Once again, borrowing from our ENT colleagues, we have learnt their technique of endoscopic sinus surgery and took it to the next step, removing pituitary tumours through the sphenoid sinus with the endoscope instead of the microscope. Undertaken by an experienced surgeon, it appears to be an elegant procedure, with potential advantages. The view can be spectacular and the endoscope can get ‘into’ the tumour cavity, and also ‘look round the corner’ into the suprasellar space and at the walls of the cavernous sinus. The nasal disturbance seems minimal and nasal packing can be avoided. As a result, postoperative nasal discomfort appears to be reduced and it is mainly the need for endocrine assessment that prolongs the inpatient stay. Most neurosurgeons undertake the procedure jointly with an ENT functional endoscopic sinus surgeon (FESS), as in the early days of microscopic trans-sphenoidal surgery. The endoscopic surgical masters, such as Jho, showed us the way, but as is often the way with pioneers, were not perhaps so concerned with the less exciting details of endocrine out come. Other centres, Naples being perhaps the best example, have provided evidence that the surgical results were about as good as standard microscopic technique and Professor Cappabianca is to be commended for the example his unit has set in teaching the technique. In the UK, as in the rest of the world, there have been early reports of groups adopting the procedure, most concentrating on the technical details and surgical complications. Until recently, the Barts/ London group had done the most to persuade us of the benefits of the technique. Ian Sabin, already an experienced microscopic pituitary surgeon together with the endoscopist Gus Alusi, discussed the ‘learning curve’, the challenges of operating with two-dimensional images and the initially increased