Commentary: Surgical Outcomes Following Repeat Transsphenoidal Surgery for Nonfunctional Pituitary Adenomas: A Retrospective Comparative Study.

Abstract

Copyright C © 2018 by the Congress of Neurological Surgeons I n their article “Surgical Outcomes Following Repeat Transsphenoidal Surgery for Nonfunctional Pituitary Adenomas: A Retrospective Comparative Study,” the authors have made a contribution to the pituitary surgery literature by adding their considerable experience at a tertiary pituitary center.1 By comparing their outcomes of first operations on large nonfunctional pituitary adenomas versus outcomes in reoperations on previously operated nonfunctional pituitary adenomas, the authors affirmed existing literature on the feasibility of reoperation, with important implications for understanding the disease process and its interventions and for presurgical patient counseling.1 Significantly, the accrual of patients in the authors’ series reflects the addition to their faculty of a skull base neurosurgeon fellowship trained in endoscopic anterior skull base techniques. Among both new operations and reoperations, the endoscopic surgeon’s number of patients treated is smaller than the number of patients in the series treated microscopically, but the endoscopic results are favorable, achieving a higher rate of gross total resection in the entire dataset than that achieved by microscopy, while having no difference in rate of persistent cerebrospinal fluid leak. This particular endoscopic surgeon’s extent-of-resection results as compared with microscopic surgery are in line with previously published comparative series in the literature while demonstrating a cumulative improvement in avoidance of persistent cerebrospinal fluid leak.2,3 Furthermore, the series reinforces the findings of a previously published series defining the overall safety and efficacy of reoperation on recurrent and progressive nonfunctional pituitary adenomas, and defines surgical prognosis in the hands of surgeons at a tertiary pituitary center with institutional experience in the pathology and all facets of its treatment. The weakness of this report remains on combination of both treatment modality in re-operations and possibly underestimating the advantage of endoscopic endonasal technique in this subset of patients. The lower gross total resection in the whole group could be a reflection of addition of microscopic technique in the reoperation group. As endoscopic transnasal transsphenoidal pituitary surgery becomes more widespread as the first-line technical option for the surgical treatment of pituitary macroadenomas,4,5 continued accrual of surgeries and postoperative follow-up will illuminate all the implications of the replacement, globally, of microscopic technique by endoscopic technique in the treatment of an ever-increasing proportion of transsphenoidal pituitary surgeries. This study represents a waypoint in this trend although it is very difficult to contribute the results of this study only to the nature of revision surgery in experienced hand and not to the treatment selection bias of using two different techniques. Further reporting of such personal and institutional experiences focused on 1 treatment modality is welcome.