Comparison of Surgical Approach to Endoscopic Pituitary Adenoma Resection
Comparison of Surgical Approach to Endoscopic Pituitary Adenoma Resection
The purpose of this study is to determine if there is a significant difference in sinonasal
 disease specific quality of life and utility scores between patients undergoing the posterior
 septectomy or Stamm approach during endoscopic pituitary adenoma resection.
Pituitary adenoma's represent 10 to 25% of all central nervous system (CNS) neoplasms and
 have an estimated population prevalence of 94 per 100,000. Asymptomatic adenomas go largely
 undetected since there is no screening protocol implemented with the purpose for early
 identification. Asymptomatic adenomas can be detected incidentally on CNS imaging for other
 indications in approximately 10% of studies and rarely require surgical intervention. In
 2011, the Endocrine Society published practice guidelines on the management of pituitary
 incidentalomas and provided the surgical indications. Incidental microadenoma's (< 10 mm)
 rarely need surgical intervention, however, incidental macroadenoma's (> 10 mm) often
 required surgical resection due to the proximity of the optic nerves and chiasm.

 Most symptomatic pituitary adenomas require transnasal transsphenoid surgical resection. Due
 to the potential for hormone secretion and location to vital structures such as the optic
 chiasm/nerves, carotid artery, and cavernous sinus, management of symptomatic pituitary
 adenomas often require a multi-disciplinary team involving neurosurgery, otolaryngology,
 neuroophthalmology, and endocrinology. Traditionally the microscope was used for
 visualization during pituitary tumor surgery, however with recent technologic advances, the
 endoscopic approach has largely replaced the microscopic approach. A recent systematic review
 and meta-analysis compared the microscopic and endoscopic approaches and have demonstrated
 that the endoscopic approach results in a significant reduction in the rate of cerebral
 spinal fluid (CSF) leak, improved tumor resection, improved patient comfort, and reduced
 hospital length of stay. Furthermore, the endoscopic approach appears to provide an overall
 cost savings compared to the microscopic approach.

 Several recent studies have demonstrated that the endoscopic approach for pituitary adenoma
 resection results in improved disease-specific quality of life (QoL) and general QoL. All
 studies have utilized the posterior septectomy approach which involves removing the posterior
 nasal septum to create a common posterior nasal cavity. The open posterior nasal cavity
 provides excellent surgical access to the sphenoid sinus and pituitary gland. Disadvantages
 of the posterior septectomy approach include the permanent posterior septal perforation which
 may predispose to postoperative crusting and epistaxis. A recent article by Stamm et al.
 described a novel endoscopic approach whereby the posterior septal mucosa is preserved while
 still providing excellent access to the sphenoid. The primary advantage of this approach is
 preventing a posterior septal defect, however disadvantages include being a more challenging
 technique and the potential for reduced surgical visualization. Furthermore, there is still a
 risk of a septal perforation due to intraoperative trauma and significant postoperative
 crusting which often develops along the surface of the healing septal mucosa. Both endoscopic
 approaches have inherent advantages and disadvantages and there has been no study comparing
 these approaches. Surgeons performing endoscopic pituitary tumor resections utilize both
 approaches and neither is considered the standard of care.

 The purpose of this randomized, single-blinded study is to determine the clinical outcomes
 between the posterior septectomy and Stamm approach for endoscopic pituitary adenoma
 resection. We hypothesize that there will be no difference in disease-specific QoL and
 general QoL between the two surgical approaches.
Inclusion Criteria:

 -  Age > 18 years old

 -  Diagnosis of a pituitary adenoma requiring resection defined as pituitary lesion with
 any of the following:

 1. Neuroimaging or clinical evidence of apoplexy

 2. Decline in central visual acuity worse than (best-corrected) Snellen equivalent
 of 20/25 in either eye

 3. clinically significant visual field loss as determined by Humphrey or Goldmann
 perimetry

 4. Clinically significant cranial nerve deficit

 5. Clinically relevant neuroendocrine deficit

 6. Intolerance of optimal medical management

 -  Patient electing endoscopic resection approach

 Exclusion Criteria:

 -  Concurrent chronic rhinosinusitis

 -  Revision pituitary adenoma resections

 -  Severe medical co-morbidities with the inability to undergo general anesthesia