Identifying risk factors for postoperative diabetes insipidus in more than 2500 patients undergoing transsphenoidal surgery: a single-institution experience

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  • 1 School of Medicine, University of California, San Diego, California;
  • | 2 School of Medicine, and
  • | 3 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 4 University of South Florida Morsani College of Medicine, Tampa, Florida;
  • | 5 Department of Neurological Surgery, University of Texas at Houston, Texas;
  • | 6 Natividad Neurosurgery, Natividad Medical Center, Salinas, California; and
  • | 7 Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
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OBJECTIVE

Diabetes insipidus (DI) following transsphenoidal surgery can adversely impact quality of life and be difficult to manage. This study sought to characterize pre- and perioperative risk factors that may predispose patients to DI after pituitary surgery.

METHODS

A retrospective review of patients treated at a single institution from 2007 to 2019 was conducted. DI was defined as postoperative sodium > 145 mEq/L and urine output > 300 ml/hr and/or postoperative desmopressin (ddAVP) use. DI was further characterized as transient or permanent. Uni- and multivariate analyses were performed to determine variables associated with postoperative DI.

RESULTS

The authors identified 2529 patients who underwent transsphenoidal surgery at their institution. Overall, DI was observed in 270 (10.7%) of the 2529 patients, with 114 (4.5%) having permanent DI and 156 (6.2%) with transient symptoms. By pathology type, DI occurred in 31 (46.3%) of 67 craniopharyngiomas, 10 (14.3%) of 70 apoplexies, 46 (14.3%) of 322 Rathke’s cleft cysts, 77 (7.7%) of 1004 nonfunctioning pituitary adenomas (NFPAs), and 62 (7.6%) of 811 functioning pituitary adenomas (FPAs). Final lesion pathology significantly affected DI rates (p < 0.001). Multivariate analysis across pathologies showed that younger age (odds ratio [OR] 0.97, p < 0.001), intraoperative CSF encounter (OR 2.74, p < 0.001), craniopharyngioma diagnosis (OR 8.22, p = 0.007), and postoperative hyponatremia (OR 1.50, p = 0.049) increased the risk of DI. Because surgery for each pathology created specific risk factors for DI, the analysis was then limited to the 1815 pituitary adenomas (PAs) in the series, comprising 1004 NFPAs and 811 FPAs. For PAs, younger age (PA: OR 0.97, p < 0.001; NFPA: OR 0.97, p < 0.001; FPA: OR 0.97, p = 0.028) and intraoperative CSF encounter (PA: OR 2.99, p < 0.001; NFPA: OR 2.93, p < 0.001; FPA: OR 3.06, p < 0.001) increased DI rates in multivariate analysis. Among all PAs, patients with DI experienced peak sodium levels later than those without DI (postoperative day 11 vs 2). Increasing tumor diameter increased the risk of DI in FPAs (OR 1.52, p = 0.008), but not in NFPAs (p = 0.564).

CONCLUSIONS

In more than 2500 patients treated at a single institution, intraoperative CSF encounter, craniopharyngioma diagnosis, and young age all increased the risk of postoperative DI. Patients with postoperative hyponatremia exhibited higher rates of DI, suggesting possible bi- or triphasic patterns to DI. Greater vigilance should be maintained in patients meeting these criteria following transsphenoidal surgery to ensure early recognition and treatment of DI.

ABBREVIATIONS

ADH = antidiuretic hormone; AP = anterior-posterior; CN = cranial nerve; ddAVP = desmopressin; DI = diabetes insipidus; FPA = functioning pituitary adenoma; GTR = gross-total resection; LOS = length of stay; ML = medial-lateral; NFPA = nonfunctioning pituitary adenoma; OR = odds ratio; PA = pituitary adenoma; POD = postoperative day; RCC = Rathke’s cleft cyst; SI = superior-inferior; SIADH = syndrome of inappropriate antidiuretic hormone; UCSF = University of California, San Francisco.

Schematics of transseptal interforniceal resection of a superiorly recessed colloid cyst. ©Mark Souweidane, published with permission. See the article by Tosi et al. (pp 813–819).

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  • 1

    Hensen J, Henig A, Fahlbusch R, Meyer M, Boehnert M, Buchfelder M. Prevalence, predictors and patterns of postoperative polyuria and hyponatraemia in the immediate course after transsphenoidal surgery for pituitary adenomas. Clin Endocrinol (Oxf). 1999;50(4):431439.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997;40(2):225237.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Wang S, Li D, Ni M, et al. Clinical predictors of diabetes insipidus after transcranial surgery for pituitary adenoma. World Neurosurg. 2017;101:110.

  • 4

    Berker M, Hazer DB, Yücel T, et al. Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary. 2012;15(3):288300.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Nemergut EC, Zuo Z, Jane JA Jr, Laws ER Jr. Predictors of diabetes insipidus after transsphenoidal surgery: a review of 881 patients. J Neurosurg. 2005;103(3):448454.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Ajlan AM, Abdulqader SB, Achrol AS, et al. Diabetes insipidus following endoscopic transsphenoidal surgery for pituitary adenoma. J Neurol Surg B Skull Base. 2018;79(2):117122.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Nayak P, Montaser AS, Hu J, Prevedello DM, Kirschner LS, Ghalib L. Predictors of postoperative diabetes insipidus following endoscopic resection of pituitary adenomas. J Endocr Soc. 2018;2(9):10101019.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Schreckinger M, Walker B, Knepper J, et al. Post-operative diabetes insipidus after endoscopic transsphenoidal surgery. Pituitary. 2013;16(4):445451.

  • 9

    Sigounas DG, Sharpless JL, Cheng DML, Johnson TG, Senior BA, Ewend MG. Predictors and incidence of central diabetes insipidus after endoscopic pituitary surgery. Neurosurgery. 2008;62(1):7179.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Devin JK. Hypopituitarism and central diabetes insipidus: perioperative diagnosis and management. Neurosurg Clin N Am. 2012;23(4):679689.

  • 11

    Schreckinger M, Szerlip N, Mittal S. Diabetes insipidus following resection of pituitary tumors. Clin Neurol Neurosurg. 2013;115(2):121126.

  • 12

    Little AS, Gardner PA, Fernandez-Miranda JC, et al. Pituitary gland recovery following fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenoma: results of a prospective multicenter study. J Neurosurg. 2020;133(6):17321738.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Burke WT, Cote DJ, Penn DL, Iuliano S, McMillen K, Laws ER. Diabetes insipidus after endoscopic transsphenoidal surgery. Neurosurgery. 2020;87(5):949955.

  • 14

    Park HR, Kshettry VR, Farrell CJ, et al. Clinical outcome after extended endoscopic endonasal resection of craniopharyngiomas: two-institution experience. World Neurosurg. 2017;103:465474.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Jeswani S, Nuño M, Wu A, et al. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study. J Neurosurg. 2016;124(3):627638.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Zada G. Rathke cleft cysts: a review of clinical and surgical management. Neurosurg Focus. 2011;31(1):E1.

  • 17

    Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH. Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg. 2005;102(2):189193.

  • 18

    de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A. Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery. 2007;61(5)(suppl 2):219228.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Gardner PA, Kassam AB, Snyderman CH, et al. Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg. 2008;109(1):616.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Jamshidi AO, Beer-Furlan A, Prevedello DM, et al. A modern series of subdiaphragmatic craniopharyngiomas. J Neurosurg. 2018;131(2):526531.

  • 21

    Benveniste RJ, King WA, Walsh J, Lee JS, Naidich TP, Post KD. Surgery for Rathke cleft cysts: technical considerations and outcomes. J Neurosurg. 2004;101(4):577584.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Gatto F, Perez-Rivas LG, Olarescu NC, et al. Diagnosis and treatment of parasellar lesions. Neuroendocrinology. 2020;110(9-10):728739.

  • 23

    Fisher C, Ingram WR. The effect of interruption of the supraopticohypophyseal tracts on the antidiuretic, pressor and oxytocic activity of the posterior lobe of the hypophysis. Endocrinology. 1936;20(6):762768.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Kiran Z, Sheikh A, Momin SNA, et al. Sodium and water imbalance after sellar, suprasellar, and parasellar surgery. Endocr Pract. 2017;23(3):309317.

  • 25

    Kristof RA, Rother M, Neuloh G, Klingmüller D. Incidence, clinical manifestations, and course of water and electrolyte metabolism disturbances following transsphenoidal pituitary adenoma surgery: a prospective observational study. J Neurosurg. 2009;111(3):555562.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Garrahy A, Thompson CJ. Management of central diabetes insipidus. Best Pract Res Clin Endocrinol Metab. 2020;34(5):101385.

  • 27

    Nadel J, Couldwell WT. Management of water and sodium disturbances after transsphenoidal resection of pituitary tumors. Neurol India. 2020;68(7)(suppl):S101S105.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Priya G, Kalra S, Dasgupta A, Grewal E. Diabetes insipidus: a pragmatic approach to management. Cureus. 2021;13(1):e12498.

  • 29

    Olson BR, Gumowski J, Rubino D, Oldfield EH. Pathophysiology of hyponatremia after transsphenoidal pituitary surgery. J Neurosurg. 1997;87(4):499507.

  • 30

    Lobatto DJ, de Vries F, Zamanipoor Najafabadi AH, et al. Preoperative risk factors for postoperative complications in endoscopic pituitary surgery: a systematic review. Pituitary. 2018;21(1):8497.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Chowdhury T, Prabhakar H, Bithal PK, Schaller B, Dash HH. Immediate postoperative complications in transsphenoidal pituitary surgery: a prospective study. Saudi J Anaesth. 2014;8(3):335341.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Han SJ, Rolston JD, Jahangiri A, Aghi MK. Rathke’s cleft cysts: review of natural history and surgical outcomes. J Neurooncol. 2014;117(2):197203.

  • 33

    Lin M, Wedemeyer MA, Bradley D, et al. Long-term surgical outcomes following transsphenoidal surgery in patients with Rathke’s cleft cysts. J Neurosurg. 2018;130(3):831837.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Pereira MP, Oh T, Joshi RS, et al. Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma. Neurosurg Focus. 2020;49(4):E19.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Oh H, Cheun H, Kim YJ, et al. Cephalocaudal tumor diameter is a predictor of diabetes insipidus after endoscopic transsphenoidal surgery for non-functioning pituitary adenoma. Pituitary. 2021;24(3):303311.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Qin J, Li K, Wang X, Bao Y. A comparative study of functioning and non-functioning pituitary adenomas. Medicine (Baltimore). 2021;100(14):e25306.

    • Crossref
    • Search Google Scholar
    • Export Citation

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