Management of nonfunctioning primary adenomas with suprasellar extensions by transsphenoidal microsurgery

BACKGROUND We evaluated the feasibility and therapeutic effectiveness of transsphenoid al microsurgical removal of nonfunctioning pituitary adenomas with suprasel lar extensions. The diagnostic modes, surgical technique, and outcome were reviewed in 208 patients with pituitary adenomas extending beyond the sella turcica who were treated by transsphenoidal microsurgery. All patients exc ept three presented with significantly diminished visual acuity and visual field defects. METHODS Diagnosis was confirmed by skull X-ray plain films, CT, or MRI scanning. Op erations were performed via a transsphenoidal approach under microscope. A subarachnoid catheter was preoperatively inserted in the lumbar cistern, th rough which saline was slowly injected during operation to increase the int racranial pressure so as to move the suprasellar tumor into the operative f ield to aid the removal. RESULTS In this series, gross total removal of an adenoma in 146 cases (70.2%) and subtotal removal in 50 cases (24.0%) was achieved; partial removal was carr ied out in the remaining 12 cases (5.8%) of fibrous or dumbbell-shaped aden omas. There were no deaths in this group. Follow-up review (median 3.8 year s) in 187 patients revealed that 97.8% of those with preoperative diminishe d visual acuity had postoperative improvement; 2.2% had no change, and none deteriorated significantly. Among 181 patients with preoperative visual fi eld defects, postoperative improvement was good in 169 (93.4%), and poor in 12 (6.6%). The major complications were diabetes insipidus and cerebrospin al fluid rhinorrhea, which occurred in 13.5% and 4.8% of patients, respecti vely. The tumors recurred in 12 patients (6.4%) who were considered to have a macroscopically complete removal at surgery. Continuing growth of residu al tumors was found in 31 (16.6%) based on visual acuity decrease, visual f ield defects, and CT or MRI examination. Of the recurrent and residual tumo rs, 4, 9, 17, and 13 cases belonged to Grades A, B, C, and D, respectively. CONCLUSIONS Comparison with transfrontal surgery suggests that these results are as goo d as those of transfrontal procedures and that the incidence of serious sid e effects is considerably lower. We consider that the microsurgical removal of pituitary tumors by the transsphenoidal approach is safe and effective even in very large or giant adenomas, since it allows rapid and adequate de compression of the optic nerves and chiasm. (C) 1999 by Elsevier Science In c.