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World Neurosurgery

Volume 83, Issue 4, April 2015, Pages 447-454
World Neurosurgery

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The Current Status of Endoscopy in Transsphenoidal Surgery: An International Survey

https://doi.org/10.1016/j.wneu.2014.12.029Get rights and content

Objective

A survey-based study was designed to assess opinions related to transsphenoidal endoscopy, to evaluate the current global attitudes of neurosurgeons regarding the use of this procedure, and to solicit basic data from key institutions worldwide, with the advantage that large series of cases become available for analysis.

Methods

A web-based multi-item questionnaire was distributed to the surgical departments of 393 neurosurgical centers by means of an invitation e-mail. The questionnaire was composed of 2 sections: section 1 focused on the surgical technique for pituitary adenomas (standard technique), and section 2 concentrated on surgery for skull base tumors (extended technique). Each section was composed of 2 parts: multiple choice questions and free textual responses.

Results

From a total of 393 neurosurgical centers, from 23 countries, that received the questionnaire, 87 of them (22%) submitted complete or incomplete responses. The surgical procedure, in 60 cases had been performed by a neurosurgeon, in 53 cases by a neurosurgeon and an otolaryngologist, and in 4 cases by an otolaryngologist only. The endoscope (2- and 3-dimensional) was used in 85.2% of transsphenoidal procedures versus the microscope in 14.8% of cases. The endonasal route was used for approach in 93.2% versus the sublabial route in 6.8% of cases. Computer-guided navigation was used by survey population in 71 cases, micro-Doppler in 51 cases, and Cavitron Ultrasonic Surgical Aspirator in 43 cases. Several hundreds of extrasellar tumors were operated using the extended technique.

Conclusions

Transsphenoidal endoscopy for pituitary and anterior skull base tumors has become established as a routine method of dealing with a variety of lesions. The level of interest in the neurosurgical surgery community is reflected by the geometric expansion of contributions to the literature on endoscopic surgery.

Introduction

Endonasal endoscopic surgery (EES) has evolved considerably since its original description 1, 3, 4, 5, 6, 7, 8, 9, 12, 13. Improved surgical technique and multidisciplinary collaboration have contributed to the widespread acceptance of this technique as an alternative treatment option for resection of many types of pituitary adenomas and anterior skull base tumors. Although the technique currently allows the successful removal of these lesions, it is not widely accepted among neurosurgeons, mainly because there is little, if any, clinical evidence that EES leads to improved long-term or short-term patient outcomes. In addition, the current viewpoint of transsphenoidal surgeons regarding the appropriate place of EES in their everyday practice is another important issue that has not been studied, and is still a subject of controversy. Furthermore, most investigators believe that before objective differences between this procedure and the classic established microscopic procedure can be adequately assessed, reports of large series of endoscopic operations and several years of patient follow-up are essential.

An understanding of these issues is essential in alleviating the current uncertainties regarding the role of endoscopy and how these can be addressed. A survey-based study was designed to assess opinions related to EES, to evaluate the current global attitudes of neurosurgeons regarding the use of this procedure, and to solicit basic data from key institutions worldwide. The advantage of such a survey is that large series of cases become available for analysis.

Section snippets

Methods

In January 2013, a web-based multi-item questionnaire was distributed to the surgical departments of 393 neurosurgical centers by means of an invitation e-mail. It was designed to obtain information concerning the current status of endoscopy in transsphenoidal surgery. It was addressed to surgeons from geographic regions with diverse cultural and professional backgrounds, training levels, and attitudes toward the new endoscopic technique.

The e-mail contained a link directing the respondents to

Demographics of the Surgeon Population and Surgical Team

Of 393 neurosurgical centers, that received the questionnaire, 87 (22%) submitted complete or incomplete responses. The respondents were from 23 countries representative of the 4 continents. In particular United States, Japan, and Italy, which was represented in 46 of 87 responses, over half of responders (Table 1).

Data displaying the demographics of the specialist population and its clinical profile allowed for addressing several issues. In 38 departments there were 89 young neurosurgeons,

Discussion

When EES was first introduced most investigatorshad objective differences between this procedure and the classically established microscopic procedure. This is evident only after the analysis of large series of endoscopic operations, with at least several years of follow-up. The advantage of a survey is the large series of cases that are available for analysis. It includes surgeons from geographic regions with diverse cultural and professional backgrounds, training levels, and attitudes toward

Conclusions

There is no doubt that EEA is playing a very important role in pituitary and cranial base tumors surgery. This technique has now proven viable for the effective removal of these lesions, and it appears likely that in the future it will be extended to other lesions currently still treated by open craniotomy. Concerns yet exist in the neurosurgical community regarding the safety of the procedure, and a potential risk of vascular injures and CSF leak substantiates this concern. Nevertheless, it

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