Endoscopic Transphenoidal Surgery: A Transition to Neurosurgery-Ent Collaboration Producing Better Outcomes

Introduction: Endoscopic transphenoidal surgery has become a mainstay in the treatment of pituitary adenomas, craniopharyngiomas, CSF leaks, and other anterior and middle skull base pathologies. Many centers employ a collaborative management team consisting of a skull base neurosurgeon working together with an ENT surgeon with expertise in advanced endoscopy. Other centers may utilize a single service strategy for management of these lesions. After performing a single service management of these lesions for the past few years, we have recently converted to a collaborative team approach for skull base endoscopy. We have appreciated significant improvements in our outcomes, especially as they relate to the rate of conversion to open (microscopic) approach and extent of resection of tumors.

Methods: A review of a prospectively maintained database was performed. We included all endoscopic transphenoidal procedures performed from August 2007 until the present time. We evaluated all endoscopic transphenoidal procedures that were performed by the neurosurgical service alone and separately evaluated those performed by a collaborative neurosurgery / ENT team. Our primary endpoint was the rate of conversion to an open microscopic procedure. Secondary endpoints were extent of resection of the neoplastic lesions, CSF leak recurrences (in the cases performed for CSF rhinorrhea), and intraoperative blood loss. Complications were also assessed and compared between the two subsets of cases.

Results: A total of 60 endoscopic transphenoidal cases were evaluated. 50 were performed by neurosurgery alone and 10 were performed by the combined neurosurgery / ENT team. There was a conversion to open microscopic approach rate of 18% in the cases done by neurosurgery alone and 0% in the combined neurosurgery / ENT cases. There was one failed CSF leak repair requiring a subsequent transcranial repair in both subsets. Extent of resection of pituitary macroadenomas was better and overall blood loss was lower in the cases performed by the combined neurosurgery / ENT team.

Conclusions: Our experience has supported the concept of achieving better outcomes in endoscopic transphenoidal surgery by using a combined neurosurgery / ENT team. We have noted a lower rate of conversion to open microscopic surgery, less blood loss, and improved extent of tumor resection.