Scientific Foundation SPIROSKI, Skopje, Republic of Macedonia Open Access Macedonian Journal of Medical Sciences. 2020 May 08; 8(B):344-349. https://doi.org/10.3889/oamjms.2020.4452 eISSN: 1857-9655 Category: B - Clinical Sciences Section: Surgery Endoscopic versus Microscopic Transsphenoidal Hypophysectomy: Comparison of the Endocrine Outcome – An Institutional Experience Robert Sumkovski1*, Ivica Kocevski1, Micun Micunovic2 1University Clinic of Neurosurgery, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia; 2Special Hospital for Orthopedic Surgery and Traumatology “St. Erazmo,” Ohrid, Republic of Macedonia Abstract Edited by: Mirko Spiroski BACKGROUND: The transnasal transsphenoidal endoscopic approach to the sella turcica is an overwhelming Citation: Sumkovsi R, Kocevski I, Micunovic M. Endoscopic versus Microscopic Transsphenoidal alternative to the microscopic approach for the past few decades assuming into prominence as a new technique, Hypophysectomy: Comparison of the Endocrine reaching nearly gold standard for this pathology. The endoscopic approach to the pituitary has redefined accurate Outcome – An Institutional Experience. Open visualization of the sella. The panoramic view afforded by the endoscope is unparalleled as compared with the Access Maced J Med Sci. 2020 May 08; 8(B):344-349. https://doi.org/10.3889/oamjms.2020.4452 traditional conical view of the microscope. Keywords: Transsphenoidal approach; Endoscopic hypophysectomy; Microscopic hypophysectomy; AIMS: This study aims to compare both endoscopic and microscopic technologies, including advantages and Endocrine outcome; Pituitary adenoma disadvantages through the results of endocrine outcome. *Correspondence: Robert Sumkovski, University Clinic of Neurosurgery, Faculty of Medicine, Saints Cyril and Methodius University of Skopje, Skopje, Republic of SETTINGS AND DESIGN: Our retrospective/prospective study included 46 microscopically and 39 endoscopically Macedonia. E-mail: [email protected] treated patients during the period of 2010–2018. Tumors were classified according to the diameter and clinical Received: 12-Mar-2020 Revised: 08-Apr-2020 outcomes were evaluated. Accepted: 04-May-2020 Copyright: © 2020 Robert Sumkovski, Ivica Kocevski, RESULTS: Our retrospective/prospective study included 46 microscopically and 39 endoscopically treated Micun Micunovic patients during the period of 2010–2018. Tumors were classified according to the diameter, hormone activity and Funding: This research did not receive any financial support clinical outcomes were evaluated. Comparison results revealed more efficacious and effective endocrine control Competing Interests: The authors have declared that no and reestablishing the endocrine homeostasis utilizing the endoscopic technique, especially in secretory active competing interest exists macroadenomas. Further, the extension of the resection, which was better in endoscopic approach undouptedly Open Access: This is an open-access article distributed under the terms of the Creative Commons Attribution- contributed to better endocrine control of the disease. Complication rate, including endocrine, was lower following NonCommercial 4.0 International License (CC BY-NC 4.0) endoscopy compared with microsurgery. CONCLUSION: This technique evidenced to have a statistically significant reduction in operative time and length of hospital stay, as well as more radical safe resection and complication control. There is also a trend toward improved endocrine outcomes and rate of return of visual defects. These two approaches are still comparable with eloquent advantages and disadvantages, formulated as balanced dialectics. In addition, the use of endoscopes, including multilocular polifilament 3D endoscope, facilitates extended approaches, reaching a delicate skull base lesions that are suprasellar, retrosellar, and parasellar, which permits visualization beyond the abilities of the microscope. Introduction corridor in the following decades [7]. Abandoned for several decades, this technique revived with Hardy in the early 1960s, introducing the operative microscope nearly Pituitary adenoma is the third most common becomes a standard approach causes it provided minimal intracranial tumor in surgical practice, accounting for morbidity and mortality [8]. The rapid global expand in approximately 10–25% of all intracranial tumors [1]. the past two–three decades emerged with Jankowski, Recent epidemiological data suggest that clinically who proposed fully endoscopic approach to pituitary apparent pituitary adenomas have a prevalence of lesions in 1992 [9]. The current high-tech development 1/1000 in the general population [2], [3]. Although of optics, radiodiagnostics, high sensitivity radio essays, only very rarely malignant, pituitary tumors may cause informatics, instrumentation, surgical devices, and utility significant morbidity in affected patients where why they tissue high-tech materials incorporated with human demand total resection, and their treatment remains innate sickness for prospect, lead to milestone progress challenge [4]. at this field. Endoscopic transsphenoidal surgery Transsphenoidal surgery of the pituitary presents safe, efficacious, effective, and minimally evolves continually beginning from the early 20th century, invasive surgery of the pituitary, which allows surgeons initially assigned by Schmidt et al., which were the to gain access to central skull base lesions in a secure first to report a sellar tumor through transsphenoidal manner defining probably the gold standard for the future. route in 1907 [5], [6]. Cushing successively focused Comprehensive cadaveric dissections, with and popularized sublabial transseptal transsphenoidal 3D evaluation in the learning curve of the pituitary 344 https://www.id-press.eu/mjms/index Sumkovski et al. Endoscopic versus Microscopic Transsphenoidal Hypophysectomy surgeons, provided meaningful baseline for expansion propagation, or cavernous sinus engagement) in this field [10]. • Other histopathological lesions The current endoscopes are two dimensional • Microadenomas favorable for conservative and cannot provide stereoscopic three-dimensional treatment view compared with the operative microscope. This fact • Previously endoscopically treated patients with dictates evaluated equivocal rationale and balanced evident complication and high risk dialectics between these two technologies. The Comprehensive neurological examination emerging new technology of 3D multilocular polifilament including motor, sensory, and cranial nerve examination endoscopes supposed to overwhelm this insufficiency. has been performed, including visual field, acuity, The purpose of this study was to compare the fundus, and evoked potentials. Routine blood and basic outcomes and the complications associated with these hormonal profile were performed. Magnetic resonance techniques by comparing endoscopic with microscopic imaging (MRI) brain and paranasal sinuses including surgery in the treatment of pituitary adenomas, sella computed tomography (CT) were performed in emphasizing the endocrine aspect. all patients. All patients underwent the standardized microscopic or endoscopic procedure and were provided a uniform post-operative care. All procedures were performed under general Materials and Methods anesthesia with orotracheal intubation. We used 4 mm diameter sinonasal rigid endoscope, “Karl Storz,” Tuttlingen, Germany, spheric Our study included eighty-five patients 0–0 and 30°. Initial phase was decongestive of the harboring pituitary adenoma, operated in our institution mucosa of the septum and turbinates. Consecutively, during the period of 2011–2018. According to the the middle meatus and sphenoid rostrum have been technology, they were separated in two groups. The identified and drilled to enter the sphenoid. Delicate first group of 46 patients treated with transsphenoidal drilling was to open the sellar floor. The dura was microscopic and endoscopically assisted microscopic opened in a crucial manner. Further, with delicate technique and the second group of 39 patients operated dissection with the pituitary instruments, the tumor has on fully endoscopically. been removed, primarily posterior and superior aspect and finally lateral and anterior portion prospectively. Second, the tumor site, the sella has been inspected Inclusion criteria with a 30° endoscope. After the tumor resection, the The following criteria were included in the basal cisternal arachnoid emerges downward pulsating. study: Hemostasis is completed usually with Surgiflo liquid surgical. The tumor cavity and sphenoid were packed • Patients with adenoma over 14 years old with fat and sealed with fibrin glue. Nasal packing was • Patients with clinically evident adenoma done with Merocel up to the middle meatus. In most • Patients with sellar lesion, according to the cases, lumbar drain has been placed for 72 h. configuration, volume, and anatomy provide safe transsphenoidal endoscopic resection Microscopic surgery was standardized and without distortion similar, except introducing Hardy’s nasal speculum • Intact diaphragm and done under visualization with a microscope pp • Patients with supra and parasellar lesion, “Pentero,” Zeiss, Germany. previously assessed for two steps resection, The hormonal profile, highly sensitive assays, initially transnasal and visual function evaluation including VEP, MRI, • Patients with microadenoma with Cushing and CT scanning were repeated