Pituitary tumors: Viewpoint—surgery

Abstract

Surgical approaches to the sellar, suprasellar, and parasellar space have evolved since their inception, with refinements in microscopic, endoscopic, and radiosurgical techniques. The gold standard for treating symptomatic nonsecreting and secreting pituitary adenomas with the exception of prolactinomas continues to be surgical resection. The goals of surgery are removal of the tumor with decompression of the optic apparatus, normalization of hormonal hypersecretion, and preservation of normal pituitary function. Before considering surgical intervention, control of preexisting medical conditions including endocrinologic abnormalities is of the essence. Also, in planning for surgery, anesthetic implications both mechanical and medical should be carefully considered. Tumor morphology and location and preexisting anatomic anomalies guide planning of the optimal surgical route. The transsphenoidal route with the assistance of a microscope or endoscope continues to be employed for most cases. The endoscope offers superior visual guidance for tumors extending from the sella and can be used as primary visual guidance or as an adjunct to a microscopic approach. Advancements in both microscopic and endoscopic transsphenoidal surgery have allowed for innovative modifications to the standard approach with the introduction of the extended approach to access regions of the skull base that were once deemed inaccessible from below. The transcranial route, however, is still indispensable in cases with significant suprasellar and mesiotemporal extension. With recurrent lesions or lesions that invade the cavernous sinus, fractionated radiation therapy and radiosurgery are adjunctive treatment modalities.​