Endonasal endoscopic pituitary surgery: is it a matter of fashion?

Dear Editor, We read with great interest the well-written review article by Michael Powell, Microscopic and endoscopic pituitary surgery, published in the July 2009 issue of Acta Neurochirurgica [5]. The author is to be particularly commended for completing a comprehensive overview of pituitary surgery based on a literature review and personal experience. The article nicely details common pituitary lesions, indications, and options for treatment. While we agree with most of the described concepts, we are concerned about the final statement of the “review” article: “No-one should change their style simply because of fashion.” As written by Powell, pituitary adenomas are “one of the most benign tumours to be found anywhere in the body,” and therefore outcome will not be dramatically changed depending upon the visualization tool used for their removal. Although not explicated by Powell, the key for increasing remission rates on the more challenging secreting pituitary adenomas (e.g., ACTH secreting) is to successfully perform an extracapsular dissection and removal of the lesion, as described by Oldfield and Vortmeyer [4], disregarding the use of the endoscope or the microscope. The dramatic difference between the endoscope and the microscope as surgical tools is related to the expanded endonasal approach. The expanded endonasal endoscopic approach is a new paradigm in skull base surgery that allows for more effective removal of ventrally located skull base lesions [3]. As an example, chordomas and chondrosarcomas can be completely removed by performing bilateral paraclival carotid mobilization with carotid canal resection, retrocarotid tumor removal, medial petrous apex drilling, abducens nerve decompression, and extradural posterior clinoid removal, if needed [2]. Craniopharyngiomas as well as diaphragmatic, tuberculum sellae and planum meningiomas can be removed with accurate preservation of vital arterial perforators, branches of the ICA, superior hypophyseal artery, and posterior communicating artery, which supply the optic apparatus and diencephalic structures [1]. Complex and invasive pituitary adenomas can spread away from the sella turcica and behave as the tumors cited above. The endoscopic approaches are far superior to microscopic ones when removing pituitary adenomas in the cavernous sinus, superior orbital fissure, Meckel’s cave, and other parasellar locations. The learning curve for such demanding surgical procedures should follow a clear pathway: intense endoscopic, microsurgical, and neuroanatomy laboratory training, dedicated observation of experienced surgeons, and progressive surgical experience. Mastering endoscopic pituitary surgery represents the mandatory requirement for pursuing expanded endonasal approaches. Is this a matter of fashion? We are convinced it is a matter of offering patients the safest and more effective surgical treatment for such challenging lesions. J. C. Fernandez-Miranda :D. M. Prevedello : P. Gardner : R. Carrau :C. H. Snyderman :A. B. Kassam Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA