Maximizing the extent of tumor resection during transsphenoidal surgery for pituitary macroadenomas: can endoscopy replace intraoperative magnetic resonance imaging?

Clinical article

Restricted access


Endoscopic approaches to pituitary tumors have become an effective alternative to traditional microscopic transsphenoidal approaches. Despite a proven potential to decrease unexpected residual tumor, intraoperative MR (iMR) imaging is infrequently used even in the few operating environments in which such technology is available. Its use is prohibitive because of its cost, increased complexity, and longer operative times. The authors assessed the potential of intrasellar endoscopy to replace the need for iMR imaging without sacrificing the maximum extent of resection.


In this retrospective study, 27 consecutive patients underwent fully endoscopic resection of pituitary macroadenomas. Intrasellar endoscopy was used to determine the presence of residual tumor within the sella turcica and tumor cavity. Intraoperative MR imaging was used to identify rates of unexpected residual tumor and the need for further tumor resection.


Intraoperative estimates of the extent of tumor resection were correct in 23 patients (85%). Of 4 patients with unacceptable tumor residuals, 3 underwent further tumor resection. After iMR imaging, the rate of successful completion of the planned extent of resection increased to 26 patients (96%). Rates of both endocrinopathy reversal and postoperative complications were consistent with previously published results for microscopic and endoscopic resection techniques.


The findings in this study provided quantitative evidence that intrasellar endoscopy has significant promise for maximizing the extent of tumor resection and is a useful adjunct to surgical approaches to pituitary tumors, particularly when iMR imaging is unavailable. A larger prospective study on the extent of resection following endoscopic transsphenoidal surgery would strengthen these findings.

Abbreviations used in this paper: FOV = field of view; GTR = gross-total resection; iMR = intraoperative MR; STR = subtotal resection.

Article Information

Address correspondence to: Philip V. Theodosopoulos, M.D., c/o Editorial Office, University of Cincinnati, Department of Neurosurgery, P.O. Box 0515, Cincinnati, Ohio, 45267-0515. email:

Please include this information when citing this paper: published online October 16, 2009; DOI: 10.3171/2009.6.JNS08916.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Drawing depicting the floor plan of a twin operating room (OR) design. Endoscopic transsphenoidal procedures were performed in the conventional OR. After tumor resection the patient was transported through a sterile corridor to the MR imaging-OR (MR-OR) for intraoperative imaging studies. The Hitachi AIRIS II 0.3-T magnet generates magnetic fringe fields that define work zones: Zone I, MR imaging–compatible instruments and equipment only; Zone II, conventional instruments; Zone IIIa, surgical microscope and computer workstations; Zone IIIb, pacemaker safe. Field strength is indicated in milliteslas. Printed with permission from Mayfield Clinic. From Bohinski RJ, Warnick RE, Gaskill-Shipley MF, et al: Neurosurgery 49:1133–1143, 2001.

  • View in gallery

    Intrasellar photograph taken with a 30° endoscope angled superolaterally to view the diaphragma sella (a), the left cavernous sinus wall (b), and a small tumor remnant (c). Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.

  • View in gallery

    Representative example of a correct prediction of GTR by MR imaging. Preoperative MR images (A and B) used to predict the extent of resection. Intraoperative MR images showing GTR with only stalk and capsular residual enhancement without (C and E) and with (D and F) contrast medium. Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.

  • View in gallery

    Representative example of a correct prediction of STR with MR imaging. Preoperative images (A and B) used to predict the extent of resection. Intraoperative MR images without (C and E) and with (D and F) contrast medium revealing optimal STR with residual tumor within the left cavernous sinus. Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.

  • View in gallery

    Representative example of an incorrect prediction of STR by MR imaging. Preoperative images (A and B) used to predict the extent of resection. Intraoperative MR images without (C and E) and with (D and F) contrast showing residual suprasellar tumor. Postoperative MR images with contrast (G and H) obtained after further resection, revealing GTR. Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.


  • 1

    Abosch ATyrrell JBLamborn KRHannegan LTApplebury CBWilson CB: Transsphenoidal microsurgery for growth hormone-secreting pituitary adenomas: initial outcome and long-term results. J Clin Endocrinol Metab 83:341134181998

  • 2

    Barahona MJSojo LWagner AMBartumeus FOliver BCano P: Determinants of neurosurgical outcome in pituitary tumors. J Endocrinol Invest 28:7877942005

  • 3

    Bohinski RJWarnick REGaskill-Shipley MFZuccarello Mvan Loveren HRKormos DW: Intraoperative magnetic resonance imaging to determine the extent of resection of pituitary macroadenomas during transsphenoidal microsurgery. Neurosurgery 49:113311432001

  • 4

    Bourdelot ACoste JHazebroucq VGaillard SCazabat LBertagna X: Clinical, hormonal and magnetic resonance imaging (MRI) predictors of transsphenoidal surgery outcome in acromegaly. Eur J Endocrinol 150:7637712004

  • 5

    Cappabianca PAlfieri AColao ACavallo LMFusco MPeca C: Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note. Minim Invasive Neurosurg 43:38432000

  • 6

    Cappabianca PAlfieri AColao AFerone DLombardi Gde Divitiis E: Endoscopic endonasal transsphenoidal approach: an additional reason in support of surgery in the management of pituitary lesions. Skull Base Surg 9:1091171999

  • 7

    Cappabianca PCavallo LMColao ADel Basso De Caro MEsposito FCirillo S: Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg 45:1932002002

  • 8

    Cappabianca PCavallo LMde Divitiis E: Endoscopic endonasal transsphenoidal surgery. Neurosurgery 55:9339402004

  • 9

    Chen JCAmar APChoi SSinger PCouldwell WTWeiss MH: Transsphenoidal microsurgical treatment of Cushing disease: postoperative assessment of surgical efficacy by application of an overnight low-dose dexamethasone suppression test. J Neurosurg 98:9679732003

  • 10

    Chuang CCChang CNWei KCLiao CCHsu PWHuang YC: Surgical treatment for severe visual compromised patients after pituitary apoplexy. J Neurooncol 80:39472006

  • 11

    de Divitiis ECappabianca PCavallo LM: Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 51:6997052002

  • 12

    De Tommasi CVance MLOkonkwo DODiallo ALaws ER Jr: Surgical management of adrenocorticotropic hormone-secreting macroadenomas: outcome and challenges in patients with Cushing's disease or Nelson's syndrome. J Neurosurg 103:8258302005

  • 13

    Esposito VSantoro AMinniti GSalvati MInnocenzi GLanzetta G: Transsphenoidal adenomectomy for GH-, PRL- and ACTH-secreting pituitary tumours: outcome analysis in a series of 125 patients. Neurol Sci 25:2512562004

  • 14

    Fahlbusch RGanslandt OBuchfelder MSchott WNimsky C: Intraoperative magnetic resonance imaging during transsphenoidal surgery. J Neurosurg 95:3813902001

  • 15

    Fahlbusch RKeller BGanslandt OKreutzer JNimsky C: Transsphenoidal surgery in acromegaly investigated by intraoperative high-field magnetic resonance imaging. Eur J Endocrinol 153:2392482005

  • 16

    Frank GPasquini EFarneti GMazzatenta DSciarretta VGrasso V: The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology 83:2402482006

  • 17

    Hammer GDTyrrell JBLamborn KRApplebury CBHannegan ETBell S: Transsphenoidal microsurgery for Cushing's disease: initial outcome and long-term results. J Clin Endocrinol Metab 89:634863572004

  • 18

    Heilman CBShucart WARebeiz EEGopal H: Endoscopic pituitary surgery. Clin Neurosurg 46:5075142000

  • 19

    Isobe KOhta MYasuda SUno THara RMachida N: Postoperative radiation therapy for pituitary adenoma. J Neurooncol 48:1351402000

  • 20

    Jane JA JrHan JPrevedello DMJagannathan JDumont ASLaws ER Jr: Perspectives on endoscopic transsphenoidal surgery. Neurosurg Focus 19:6E22005

  • 21

    Jane JA JrThapar KKaptain GJMaartens NLaws ER Jr: Pituitary surgery: transsphenoidal approach. Neurosurgery 51:4354422002

  • 22

    Jarrahy RBerci GShahinian HK: Assessment of the efficacy of endoscopy in pituitary adenoma resection. Arch Otolaryngol Head Neck Surg 126:148714902000

  • 23

    Jho HD: Endoscopic transsphenoidal surgery. J Neurooncol 54:1871952001

  • 24

    Jho HDAlfieri A: Endoscopic endonasal pituitary surgery: evolution of surgical technique and equipment in 150 operations. Minim Invasive Neurosurg 44:1122001

  • 25

    Jho HDCarrau RL: Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 87:44511997

  • 26

    Kabil MSEby JBShahinian HK: Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg 48:3483542005

  • 27

    Kreutzer JVance MLLopes MBLaws ER Jr: Surgical management of GH-secreting pituitary adenomas: an outcome study using modern remission criteria. J Clin Endocrinol Metab 86:407240772001

  • 28

    Kristof RASchramm JRedel LNeuloh GWichers MKlingmuller D: Endocrinological outcome following first time transsphenoidal surgery for GH-, ACTH-, and PRL-secreting pituitary adenomas. Acta Neurochir (Wien) 144:5555612002

  • 29

    Laws ERVance MLThapar K: Pituitary surgery for the management of acromegaly. Horm Res 53:Suppl 371752000

  • 30

    Meij BPLopes MBEllegala DBAlden TDLaws ER Jr: The long-term significance of microscopic dural invasion in 354 patients with pituitary adenomas treated with transsphenoidal surgery. J Neurosurg 96:1952082002

  • 31

    Mortini PLosa MBarzaghi RBoari NGiovanelli M: Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 56:122212332005

  • 32

    Nemergut ECZuo ZJane JA JrLaws ER Jr: Predictors of diabetes insipidus after transsphenoidal surgery: a review of 881 patients. J Neurosurg 103:4484542005

  • 33

    Nimsky Cvon Keller BGanslandt OFahlbusch R: Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 59:1051142006

  • 34

    Nomikos PBuchfelder MFahlbusch R: The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical ‘cure’. Eur J Endocrinol 152:3793872005

  • 35

    Park PChandler WFBarkan ALOrrego JJCowan JAGriffith KA: The role of radiation therapy after surgical resection of nonfunctional pituitary macroadenomas. Neurosurgery 55:1001072004

  • 36

    Schroeder HWGaab MR: Intracranial endoscopy. Neurosurg Focus 6:4e11999

  • 37

    Schulder MSernas TJCarmel PW: Cranial surgery and navigation with a compact intraoperative MRI system. Acta Neurochir Suppl 85:79862003

  • 38

    Schwartz THStieg PEAnand VK: Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58:ONS44ONS512006

  • 39

    Selman WRLaws ER JrScheithauer BWCarpenter SM: The occurrence of dural invasion in pituitary adenomas. J Neurosurg 64:4024071986

  • 40

    Sudhakar NRay AVafidis JA: Complications after transsphenoidal surgery: our experience and a review of the literature. Br J Neurosurg 18:5075122004

  • 41

    Sullivan LJO'Day JMcNeill P: Visual outcomes of pituitary adenoma surgery. St Vincent's Hospital 1968–1987. J Clin Neuroophthalmol 11:2622671991

  • 42

    Tsang RWBrierley JDPanzarella TGospodarowicz MKSutcliffe SBSimpson WJ: Radiation therapy for pituitary adenoma: treatment outcome and prognostic factors. Int J Radiat Oncol Biol Phys 30:5575651994

  • 43

    Tyrrell JBLamborn KRHannegan LTApplebury CBWilson CB: Transsphenoidal microsurgical therapy of prolactinomas: initial outcomes and long-term results. Neurosurgery 44:2542611999

  • 44

    Wilson CB: A decade of pituitary microsurgery. The Herbert Olivecrona lecture. J Neurosurg 61:8148331984




All Time Past Year Past 30 Days
Abstract Views 180 180 39
Full Text Views 184 184 2
PDF Downloads 159 159 1
EPUB Downloads 0 0 0


Google Scholar