Outcomes Following the Transplanum Transtuberculum Approach to Suprasellar Lesions

Objective: The endoscopic endonasal transplanum, transtuberculum approach provides a direct route to pathology in the suprasellar cistern. The purpose of this study is to present an overview of the indications, limitations, results, and complications of this approach in a large series of patients.

Methods: This is a prospective observational study of 41 consecutive patients who underwent endoscopic, endonasal transplanum, transtuberculum surgery between March 2004 and August 2008. The series consists of 46 procedures that include 11 pituitary macroadenomas, 2 Rathke's cleft cysts, 13 craniopharyngiomas, 10 meningiomas, 4 vascular tumors, and 1 germinoma.

Results: The mean age was 51.7 years (range, 9–80 years) with 16 male patients. Patients were divided based on the intention of the surgeon to achieve gross total resection (GTR) versus palliative debulking. Resections were categorized as GTR ( > 95%), near total resection (75–95%), subtotal resection (25–75%), or biopsy (patients were not eligible for GTR). Six patients of the eleven patients with a pituitary macroadenoma underwent GTR; three of these patients had a near total resection, and two underwent palliative subtotal resections. Six total, two near total, and two partial resections were performed in the meningioma patient population. Visual symptoms resolved in 11 patients, improved in 12, did not change in 3, and worsened in 1 patient. Eleven patients developed postoperative endocrine dysfunction with transient diabetes insipidus as the most frequent deficit. There were only two cerebrospinal fluid (CSF) leaks (4.3%) in the series-one was complicated by meningitis and was the only fatality in this series, and the other resolved with lumbar drainage. One patient developed epistaxis, two were treated with one successful course of antibiotics for sinusitis, and one patient required washout of an abscess at the skull base reconstruction site.

Conclusion: The extended endoscopic approach to suprasellar lesions is a minimally invasive alternative to craniotomy. The incidence of CSF leak is low, particularly as techniques for closure evolve and become more secure. There is significant improvement in vision. We believe that this technique compares favorably with the best microscopic series in terms of complication and resection rates.