====== Endoscopic Transsphenoidal Approach for Pituitary Neuroendocrine Tumors (PitNETs) ====== ==== Introduction ==== The **[[endoscopic transsphenoidal approach]] (ETSA)** has become the standard surgical method for [[PitNET]]s, offering advantages over the traditional microscopic [[approach]], including improved [[visualization]], better tumor [[resection]] [[rate]]s, and lower [[complication]] rates. ==== Surgical Approach: Endoscopic Transsphenoidal Surgery (ETSS) ==== === 1. Indications === * Functioning PitNETs (GH-secreting, ACTH-secreting, PRL-secreting, TSH-secreting) * Non-functioning PitNETs (gonadotroph, null-cell tumors) * PitNETs causing mass effect (optic chiasm compression, cavernous sinus invasion) * Recurrence after prior surgery === 2. Advantages of Endoscopic vs. Microscopic Approach === ^ Feature ^ Endoscopic Approach ^ Microscopic Approach ^ | **Visualization** | Wide-angle, panoramic | Narrower field | | **Depth Perception** | 3D with angled endoscopes | 2D view | | **Tumor Resection** | Better for suprasellar & cavernous sinus extension | Limited | | **Invasiveness** | Less nasal trauma | More retraction required | | **Complication Rate** | Lower risk of CSF leaks, nasal complications | Higher risk of damage to nasal structures | ==== Outcomes & Complications ==== === 1. Surgical Outcomes === * **Resection Rates**: Gross total resection (GTR) ~50-80% (dependent on tumor size, invasiveness) * **Endocrine Remission**: Varies by tumor type (e.g., GH-secreting ~60%, ACTH-secreting ~70-80%) * **Visual Improvement**: ~85% of patients with preoperative visual deficits === 2. Complications === ^ Complication ^ Incidence (%) ^ Notes ^ | **CSF leak** | 5-10% | Higher in large, invasive tumors | | **Diabetes insipidus (transient)** | 20-30% | Most cases resolve spontaneously | | **Permanent DI** | ~2-5% | Requires desmopressin | | **Hypopituitarism** | 5-25% | May require hormone replacement | | **Carotid artery injury** | <1% | Life-threatening, rare | ==== Future Directions ==== * **Augmented Reality & AI-based neuronavigation** to enhance surgical precision * **Endoscopic-assisted robotic surgery** for improved dexterity * **Minimally invasive transorbital approaches** for extended cases ==== Conclusion ==== The **endoscopic transsphenoidal approach** has revolutionized the surgical treatment of PitNETs, offering **better visualization, higher resection rates, and lower complication risks** compared to traditional microscopic surgery. While the approach has limitations in highly invasive tumors, technological advancements continue to improve outcomes. ===== Retrospective multicenter observational studies ==== TESSPAIN evaluates TSS outcomes in Spanish centers to assess the influence of surgical volume and specialized neurosurgical [[team]]s on success and complication rates. A retrospective, nationwide study of Spanish centers performing TSS between January [[2018]] and December [[2022]]. Centers were classified as high volume (HV) [n=11, defined as centers with recognized expertise in Spain or those performing more than 25 TSS/year] or non-HV. Data collection included surgical success rates, complications, and pituitary adenoma resectability (R-PA). Additional analyses evaluated the impact of dedicated neurosurgical teams (DNT) within HV centers. 2815 TSS from 29 Spanish centers were included (1421 NSPA, 436 GH-secreting, 323 Cushing's disease, 127 PRL-secreting, and 25 TSH-secreting PA). The overall success rate was 50.5%, 76.8% for R-PA. HV centers had a higher overall success rate (53.1 vs. 47.7%; p=0.03). Better TSS outcomes for NSPA accounted for this difference. The overall TSS complication rate was 22.1%, which was higher for NSPA than for SPA (25.0 vs. 17.7%). The overall complication rate of TSS for PA was significantly higher in non-HV centers than in HV centers (24 vs 20.4.0; p <0.01). Centers with a DNT showed a trend to higher success rate in R-PA, while having a lower overall incidence of complications in TSS for PA than HV centers without a DNT (18.5 vs. 23.0; p=0.058), mainly reducing the rate of permanent ADH deficiency in all TSS for PA (2.7 vs. 8.4%; p<0.001). Higher [[surgical volume]] and DNT are associated with improved TSS outcomes for PA in [[Spain]]. The results support the [[recommendation]] of concentrating [[pituitary surgery]] in a reduced number of centers of expertise in the [[country]] to improve the success rate and reduce complications, mainly postoperative ADH deficiency ((Paja M, Soto A, Hanzu FA, Guerrero-Pérez F, Cámara R, Moure D, Gálvez Á, Simó-Servat A, Villar-Taibo R, Calatayud M, Vicente A, Recio-Córdova JM, Serra G, Martín Rojas-Marcos P, Parra-Ramírez P, Araujo-Castro M, Librizzi S, Irigaray A, Ollero D, Aznar S, Muñoz F, Aulinas A, González-Fernández L, García-Centeno R, Egaña N, González-Vidal T, Menéndez E, Delgado AM, Abarca J, Sottile J, Picó AM, Novo C, Ortiz I, Tenorio C, de León R, de Pablos-Velasco P, Crespo C, Peñalver D, Díaz-Soto G, Puig-Domingo M, Biagetti B. [[Outcome]]s of [[transsphenoidal surgery]] for [[pituitary adenoma]]s in [[Spain]]: a [[retrospective]] [[multicenter study]]. Front Endocrinol (Lausanne). 2025 Feb 21;16:1529418. doi: 10.3389/fendo.2025.1529418. PMID: 40060376; PMCID: PMC11886961.))