Advances in neuroendoscopic treatment of pituitary tumors

Pituitary tumors, accounting for 10–15% of intracranial neoplasms, often cause significant morbidity due to hormonal dysregulation and compression of surrounding structures. While traditionally managed via open craniotomy or microscopic transsphenoidal surgery, neuroendoscopic techniques have revolutionized treatment by offering minimally invasive, high-precision alternatives. This review synthesizes recent advancements in neuroendoscopic surgery for pituitary tumors, focusing on pathogenesis, technological innovations, clinical outcomes, and future directions. Despite its advantages—including higher gross total resection (GTR) rates (87.9% vs. 66.0% for microscopy) and improved biochemical remission—challenges such as a steep learning curve, instrument maneuverability limitations, and cerebrospinal fluid (CSF) leak risks persist. Future research should prioritize enhanced instrument design, 3D/augmented reality systems, and standardized training programs to optimize outcomes.

Introduction
Pituitary tumors, though typically benign, can lead to severe complications through hormone hypersecretion or mass effects on adjacent structures like the optic chiasm. The shift from open craniotomy to neuroendoscopic transsphenoidal surgery has marked a paradigm shift in treatment, reducing surgical trauma and improving recovery times. However, challenges remain in managing large, invasive, or recurrent tumors, compounded by incomplete understanding of their molecular pathogenesis. This review highlights the transformative role of neuroendoscopy while addressing its limitations and future potential.

Pathogenesis of Pituitary Tumors
Pituitary tumorigenesis involves genetic and epigenetic alterations (e.g., gsp oncogene activation, MEN1 mutations) disrupting cell proliferation and hormone regulation. Dysregulated signaling pathways (MAPK/ERK, PI3K/Akt/mTOR) and environmental factors (radiation, obesity) further drive progression. Functioning tumors (e.g., prolactinomas, growth hormone-secreting adenomas) cause hormonal syndromes, while non-functioning tumors impair pituitary function through compression.

Neuroendoscopic Technology
Neuroendoscopy enables transnasal access to the sella turcica (Figure 1), eliminating cranial openings. Key advancements include:

1. High-resolution imaging: 3D endoscopy and augmented reality enhance visualization of tumor margins and critical structures.

2. Miniaturization: Flexible endoscopes improve access to complex regions like the cavernous sinus.

3. Navigation and robotics: Real-time tracking and robotic assistance increase precision.

4. Chopsticks technique: Allows single-handed operation of multiple instruments, optimizing efficiency in narrow corridors.

Clinical Outcomes
Neuroendoscopy demonstrates superior outcomes across pituitary tumor subtypes:

• Non-functioning adenomas: GTR rates of 70–90%.

• Prolactinomas: Biochemical remission in 70–90% of microadenomas.

• Acromegaly (GH-secreting): Remission in 60–80% of macroadenomas.

• Cushing’s disease (ACTH-secreting): Remission in 80–95% of microadenomas.
  Benefits include shorter operative times, reduced blood loss, and faster recovery compared to microscopy.

Limitations

1. Learning curve: Requires extensive training due to complex skull base anatomy.

2. Instrument constraints: Limited maneuverability in narrow spaces.

3. CSF leaks: Occur in ~5–15% of cases, necessitating improved reconstruction techniques.

4. Cost: High equipment expenses limit accessibility.

Future Directions

1. Technological innovations:

   • Robotic-assisted systems for enhanced precision.

   • Biomaterials for durable skull base reconstruction.

2. Training: Simulation-based programs to standardize skills.

3. Molecular therapies: Targeted drugs for resistant/recurrent tumors.

Conclusion
Neuroendoscopic surgery has redefined pituitary tumor management, offering minimally invasive resection with high efficacy. While challenges like the learning curve and CSF leaks persist, ongoing advancements in imaging, robotics, and training promise to further refine the technique. Future integration with molecular therapies could revolutionize outcomes for complex cases.

Full text:

https://www.xiahepublishing.com/3067-6150/NSSS-2024-00008

The study was recently published in the Neurosurgical Subspecialties.

Neurosurgical Subspecialties (NSSS) is the official scientific journal of the Department of Neurosurgery at Union Hospital of Tongji Medical College, Huazhong University of Science and Technology. NSSS aims to provide a forum for clinicians and scientists in the field, dedicated to publishing high-quality and peer-reviewed original research, reviews, opinions, commentaries, case reports, and letters across all neurosurgical subspecialties. These include but are not limited to traumatic brain injury, spinal and spinal cord neurosurgery, cerebrovascular disease, stereotactic radiosurgery, neuro-oncology, neurocritical care, neurosurgical nursing, neuroendoscopy, pediatric neurosurgery, peripheral neuropathy, and functional neurosurgery.

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