Endonasal Transsphenoidal Surgery

A highly skilled neurosurgical team is directed by Sandeep Kunwar, MD, specializing in transsphenoidal surgery for pituitary adenomas and parasellar lesions. The objective of the surgical team is always to optimize cure and preserve gland function.

Advantages to the Endonasal Transsphenoidal Operation

• No intranasal or sublabial incisions
• No nasal packing
• Improved visualization and illumination with the use of an endoscope
• 85% of patients return home the day after surgery, regardless of tumor size
• Complete removal of tumors as large as 5 cm
• Extensive experience minimizes risk of recurrence or need for postoperative radiotherapy
• Tumor is removed with preservation of the normal gland
• Minimal blood loss
• Low complication rates (0% mortality in over 1000 operations, <1% major morbidity)
• New techniques to eliminate CSF leak

Extended Transsphenoidal Surgery

Extended transsphenoidal surgery extends into the brain cavity without requiring a craniotomy and is used to treat tumors that cannot be reached by the standard method, including meningiomas, chordomas, and chondrosarcomas, as well as clival tumors, craniopharyngiomas, and tumors of the hypothalamus or optic nerves.

Left: Coronal post contrast-enhanced T1-weighted MR image shows a large enhancing pituitary macroadenoma displacing the optic chiasm and deforming the floor of the sella. Right: Three-month post-transsphenoidal resection of adenoma shows no residual disease and normal optic nerves.

Craniotomy

Craniotomy for pituitary adenomas is very rare, but minimally invasive keyhole craniotomy is a treatment option, if necessary. Even large pituitary adenomas can now be approached by the extended transsphenoidal approach.

FAQs About Treating Pituitary Adenomas With Neurosurgical Removal

Pituitary adenomas may be more common than has previously been thought. Tiny adenomas of the pituitary gland that can be seen only through a microscope may never cause a health problem for some people, but in others growth of the adenoma can cause a variety of symptoms. The following are questions that patients often ask about the nature of pituitary adenomas and their treatment by surgical removal.

What is the pituitary gland?

Located in the center of the head, behind the eyes and the optic nerve, the pituitary gland rests in the sella turcica, above the sphenoid sinus. The pituitary gland is small (about the size of a kidney bean, 10 mm, or less than 1/2 inch, in diameter), but it has very important functions because it secretes several hormones that regulate essential body processes.

What is a pituitary adenoma?

A pituitary adenoma is a tumor—that is a growth of tissue in which cells multiply in an uncontrolled manner. Adenomas are located just next to, or within the pituitary gland. The adenoma can be much smaller than the gland when the symptoms it causes become noticeable and the adenoma is diagnosed. Most pituitary adenomas are ‘microadenomas,’ which measure 3 to 9 mm (1/8 to 3/8 of an inch) in diameter, although a few patients have ‘macroadenomas,’ which are 10 mm or larger in diameter. Macroadenomas often cause problems with normal pituitary function because of compression of the gland or vision problems from compression of the optic nerves. Almost all adenomas are benign, rather than malignant, which means that they are relatively slow-growing and are slow to invade surrounding tissues. They very rarely metastasize or spread to other areas of the body.

What happens during surgery?

The surgical removal of the pituitary adenoma is performed by a technique called a transsphenoidal operation. The word ‘transsphenoidal’ describes the path the surgeon follows to reach the pituitary gland. The word comes from ‘trans’, meaning ‘to cross or pass through’, and ‘sphenoid’, the name of the cavity (the sphenoid sinus) that is passed through to reach the pituitary gland. Newer techniques and improvements in technology now allow removal of these tumors without the need for an incision under the lip or within the nostril. The surgeon begins the approach by entering through the nostril on one side. The surgeon uses a brilliant fiber optic light to illuminate the internal anatomy, a microscope to magnify the area of surgery to 12 times the actual size, and very tiny microsurgical instruments especially designed for this particular operation. The surgeon guides the surgical instrument into the nasal cavity and an opening is made in the sphenoid bone. The sphenoid sinus is entered, and then an opening is made in the wall of the sella turcica to expose the pituitary gland. The adenoma can be readily distinguished from the normal pituitary gland tissue and is removed without removing the normal gland. After the surgeon removes all the tumor tissue, the small cavity that is left is treated with alcohol to destroy any tumor cells that may remain. This cavity is then sealed, sometimes with a piece of fat that the surgeon removes from the patient’s abdomen. The surgeon then applies a biological ‘glue’ that helps seal the pituitary area from the nose and promotes natural healing. No nasal packs are used with this approach.

Sometimes it is necessary to place a ‘spinal drain’ during surgery. This ‘drain’ is a tiny tube that is threaded into the space in the lower back that is occupied by spinal fluid. This tube allows the surgeon to remove spinal fluid or inject saline solution into the spinal fluid space. Because the spinal fluid in the lower back flows in together with the fluid around the brain and pituitary gland, changes in the level of the fluid in the spinal area can move the pituitary gland in such a way that the surgeon can remove the tumor more easily. Some patients wake up after the operation with mild lower-back pain, a band-aid on their back, and in some cases a drainage bag that will remain in place for 24 hours.

What will the surgery be like?

Patients are usually given antibiotic nose drops, which they are asked to use for 2 days before their operation to discourage the growth of bacteria. At the scheduled time when patients arrive at the hospital, they are accompanied to the preoperative care area, where they are given a surgical gown, slippers, and a warm blanket, and their care by several nurses and doctors begins.

Once in the operating room for surgery, the patient is given general anesthesia. A neuroanesthesiologist administers the anesthesia and stays with patients throughout the operation to assure that they respond properly to the anesthetics at all times. Surgery, then, is performed while the patient is asleep. A tube is inserted into the patient’s throat and stays there during the operation to assure that breathing is not obstructed.

What happens in the recovery room?

After surgery, most patients regain full consciousness in the recovery room, although people differ in their responses to anesthesia and some feel drowsy for a while after they return to their own hospital room. During the first few hours after the operation, there will be several people—both doctors and nurses—attending the patient. They monitor the blood pressure, pulse, and level of alertness, and they check the patient’s eyes and ask the patient to perform certain simple tasks, which are tests to be sure that recovery is going well.

Will I have pain when I wake up?

Some patients find that their throat is sore from the tube that was placed there during surgery. Some patients have sinus headaches and pain medication will be prescribed. Patients are always reminded not to hesitate to let the nurses know if they have any discomfort.

Will I have any additional discomfort?

The patient’s nose will be dry and possibly tender because of surgery. A salt-water nasal spray will be provided to help keep the nasal membranes moist. Typically, there is no swelling or bruising of the face after surgery.

What activities may I resume?

Most patients feel well enough to get up on the evening of the day they have their operation. Most patients are able to get up to go to the bathroom with assistance overnight. The morning after surgery, most patients are able to walk in the hallways independently or with minimal assistance. Typically, patients are discharged from the hospital after lunch on the first day after the operation. For the first few days at home, people find that they tire very easily and need naps or rest periods.

May I eat and drink?

Patients are not given anything to drink after surgery until they are fully awake. An intravenous (IV) needle placed in the arm provides fluids until the patient can drink adequately. Most people are able to drink liquids on the evening of the operation. Patients can have solid foods when they are able to tolerate them—usually at breakfast on the day after surgery.

Why will it be necessary to measure my fluid intake and output?

The hormones of the pituitary gland control fluid balance, and occasionally after surgery an imbalance can occur. It is possible to detect any imbalance by measuring all of the patient’s fluid intake and all urinary output. During this time patients and their families need to make sure the nurse is aware of anything extra the patient might drink, such as a milkshake brought in by family members. Patients may notice an increase in thirst or an increase in urinary output. The body can usually control increased urinary output by making patients feel more thirsty; but patients who are urinating large amounts may be given a medication to help control this.

Will I be able to breathe through my nose?

Yes. Patients no longer have nasal packing placed, and can therefore breathe through both nostrils immediately after surgery. However, most patients will have nasal congestion and a runny nose for several days. Sometimes, a small ‘sling’ type dressing is placed under the patient’s nose and is changed by the nurses as needed. Decongestant pills will be provided to relieve any sinus headaches and congestion that occurs.

How long will it be before I will feel better?

Within 48 to 72 hours after the transsphenoidal operation, most of any significant discomfort will be over, and patients are on their way to recovery. The feeling of tiredness may last several weeks, and patients are encouraged to walk and increase their physical activity as tolerated. After 4 weeks from surgery, there are no limitations in physical activity.