Transsphenoidal surgery

Transsphenoidal, sometimes called transsphenoidal surgery, is a procedure to remove tumors from the pituitary gland and nearby areas in the skull base. The pituitary gland is a small, pea-sized gland in the skull behind the nose. It manages hormone levels in the body.

Small noncancerous tumors, also called benign tumors, may grow in the pituitary gland. Rarely, these tumors can be cancerous, also called malignant. Transsphenoidal surgery involves reaching the pituitary gland by going through the nose into the space behind it called the sphenoid sinus.

The transsphenoidal surgery approach is minimally invasive. This means that the surgeon doesn’t need to cut open your skull to reach the pituitary tumor. There are generally fewer complications and a shorter hospital stay than if you had traditional brain surgery. In transsphenoidal surgery, the surgeon uses very small instruments to access the tumors, going underneath the brain through the nasal passages and the sphenoid sinus.

Transsphenoidal surgery also may be called endoscopic transnasal transsphenoidal surgery, endoscopic pituitary surgery or transsphenoidal hypophysectomy. Hypophysectomy means to remove tumors or part of the pituitary gland, also called the hypophysis.

Transsphenoidal surgery is usually done to remove pituitary gland tumors. While there are many types of pituitary tumors, the most common type removed in transsphenoidal surgery is pituitary adenoma. These noncancerous, also called benign, tumors produce too much of certain kinds of hormones. This can cause problems such as irregular menstrual periods, weight gain, sexual dysfunction and atypical growth. Pituitary adenomas also can cause hyperthyroidism, Cushing’s disease and other hormone-related disorders by making too much of a hormone.

Transsphenoidal surgery may be done to remove functioning and nonfunctioning tumors. Functioning tumors release hormones into the body, while nonfunctioning tumors do not release any or enough hormones to cause symptoms.

Tumors that are not making excessive hormones are called nonfunctioning adenomas, also called NFAs. Large pituitary adenomas may need to be removed by surgery if the tumor is causing symptoms. Surgery also may be needed to help the pituitary gland work properly. Small pituitary adenomas that are less than 0.4 of an inch (10 millimeters) in size may not need to be removed unless they cause concerns or symptoms. They may be monitored with regular imaging tests, such as MRI or CT.

Transsphenoidal surgery also may be done to remove other kinds of growths in the area around the pituitary gland. These can include:

• Craniopharyngiomas, benign tumors that can cause vision problems.
• Rathke cleft cysts, benign sacs of fluid that can press on the pituitary gland or the nerves to the eyes.
• Meningiomas, tumors that can grow from the membranes that surround the brain.
• Chordomas, rare cancerous bone tumors that grow at the skull base and may expand into the area around the pituitary gland.
• Chondrosarcomas, bone tumors similar to chordomas.
• Prolactinomas, benign tumors that cause an increase in the hormone prolactin.

The main goals of transsphenoidal surgery are to restore healthy function of the pituitary gland, to remove the tumor and to keep the tumor from growing back. Transsphenoidal surgery also may be done to:

• Manage symptoms caused by tumors on or near the pituitary gland. These symptoms can include headaches and problems with vision.
• Manage the production of hormones.
• Stop tumor growth and prevent damage to the pituitary gland, optic nerves and nearby parts of the brain.
• Take a small sample of tumor tissue, called a biopsy, to diagnose the type of tumor and help plan treatment.
• Remove part of the tumor in cases where removing the whole tumor may be harmful. Removing even part of the tumor helps other therapies work better.
• Treat pituitary apoplexy, an emergency in which the pituitary tumor suddenly bleeds heavily or the blood flow is blocked within the tumor.
• Treat acromegaly, a condition caused by excess production of growth hormone, usually caused by a pituitary gland tumor.

Transsphenoidal surgery is generally considered low risk for most people. But as with any procedure, there are some possible risks. These may include:

• Leaking cerebrospinal fluid. This is the most common complication. After the procedure, the fluid may leak from the nose. Sometimes, another surgery is needed to stop the leak.
• Arginine vasopressin deficiency (AVD). Previously known as central diabetes insipidus, AVD can develop as a complication if the pituitary gland is damaged during transsphenoidal surgery. AVD happens when there isn’t enough of the ADH hormone and the body loses too much water. It causes frequent urination and feeling very thirsty. This can sometimes interfere with sleep. This may be temporary or permanent, but AVD can be treated with medicine.
• Hypopituitarism. If the pituitary gland is damaged, another possible complication is loss of hormone production. The pituitary gland may completely stop producing hormones, or it may produce less than the usual amount. This can be treated with lifelong hormone therapy.
• Bleeding. If a blood vessel is damaged during the procedure, bleeding can occur. This bleeding can be serious and may lead to a stroke if the carotid artery is damaged. This complication is very rare, and can usually be well managed by the surgeon. Even if bleeding occurs, the risk of stroke is very low.
• Infection. The most common risk of infection is to the membranes surrounding the brain and spinal cord, called meningitis. This is more likely to happen if you have a cerebrospinal fluid leak, or if you have a sinus infection at the time of surgery. Despite the amount of bacteria in the nose, transsphenoidal surgery through the nose has a low risk of infection.
• Vision problems. If the optic nerves are damaged, you may have partial or total vision loss or blurry vision. This complication is very uncommon.
• Sinus problems. Infection in the sinuses, called sinusitis, stuffy nose and loss of sense of smell are possible complications.
• Electrolyte imbalances. This happens when the levels of electrolytes, which are types of minerals, in the body are too high or too low. Electrolytes, including sodium, potassium and calcium, help maintain the function of muscles. Electrolytes also manage the amount of water in your body.

Your healthcare professional likely will talk to you about what you need to do to prepare for transsphenoidal surgery. Some of the steps you may take with your healthcare team include:

• Physical exam and medical history.
• Eye exams to check for vision problems.
• Blood tests to check for infection, measure hormone levels and get a sense of your overall health.
• Imaging tests, such as MRI or CT, to help the healthcare team plan your surgery.

If your healthcare professional finds anything that may interfere with your surgery, such as irregular hormone levels, you may take steps to manage that before your surgery.

People with an underactive thyroid gland, also called hypothyroidism, may need to take medicine to manage the condition before surgery.

Food and medicines

Your healthcare professional will let you know if you need to stop or change any of your regular medicines prior to the surgery.

You may need to stop all food and drink the night before your surgery. You also may need to stop smoking and drinking alcohol for a couple of weeks before your surgery. Ask your healthcare team for specific instructions.

You’ll need to have someone drive you home from the hospital after your transsphenoidal surgery. You may need someone to stay with you at home for a period of time while you recover.

Before transsphenoidal surgery

Before the day of your surgery, you may have imaging tests, such as MRI or CT, to help the surgeon locate the tumor and plan the surgery.

Transsphenoidal surgery usually requires general anesthesia. This means that you will have medicine that puts you in a sleeplike state during the surgery so that you don’t feel any pain.

Your healthcare team may clean the inside of your nose with a solution to help prevent infections.

During transsphenoidal surgery

Transsphenoidal surgery usually takes somewhere between two and four hours. The care team usually includes both a neurosurgeon and an ear, nose and throat surgeon, also called an ENT surgeon. Your heart rate, blood pressure and oxygen levels are monitored throughout the surgery.

You will lie on an operating table on your back with your head placed in a headrest. Your head may need to be slightly raised during the surgery. Depending on the location of the tumor, you may be in a slightly different position, or your body tilted a certain way.

Endoscopic transsphenoidal surgery uses a thin tube equipped with a camera and a light, called an endoscope, threaded through a nostril. When this procedure is done in only one nostril, it’s called uninaral or unilateral. When it’s done in both nostrils, it’s called binostril. The endoscope also runs through the sphenoid sinus, a hollow space just behind the nose. This is sometimes called an endonasal approach because the endoscope reaches the sphenoid sinus through the nostril.

In some cases, the surgeon makes a small cut in the wall of tissue and cartilage that separates the nostrils, called the nasal septum, and moves the mucosal layer to reach the sphenoid sinus. This is called the submucosal approach.

Using very small instruments, the surgeon removes a small piece of bone, called the sella turcica. Then, the surgeon cuts through the strong membrane covering the brain, called the dura, to reach the pituitary gland. Then, the surgeon removes the tumor. This is often done in small pieces rather than removing the entire tumor at once.

The surgeon may use a small piece of tissue or fat from somewhere else in your body to pack the area, and close with surgical glue. This also will help prevent cerebrospinal fluid leaks.

Endoscopic transsphenoidal surgery is the most commonly performed type of transsphenoidal surgery. Sometimes, transsphenoidal surgery is done microscopically, using a microscope to guide the surgeon instead of an endoscope. Which type of surgery you have may depend on several factors, including the surgeon’s experience.

After transsphenoidal surgery

After transsphenoidal surgery is finished, you’ll wake up in a recovery room. Your healthcare team will continue to monitor your breathing, heart rate and other vital signs while you recover and begin to wake.

Most people have to stay in the hospital after transsphenoidal surgery. The typical stay is between one and three days, but most people only need to spend one night in the hospital. While you’re at the hospital, your healthcare team will continue to monitor your hormone levels to make sure the pituitary gland is functioning as expected and hormone and electrolyte levels are healthy.

Most people don’t experience much pain after transsphenoidal surgery. Some people have a headache or some stuffiness in the nose. You may have some discharge running from your nose after the surgery. The discharge may be thick or bloody. You may wear a bandage to help with the discharge. Your healthcare professional may suggest rinsing your nasal passages with saline.

You won’t be able to see any scars, stitches or cuts from the surgery.

Restrictions after transsphenoidal surgery

You may be asked to take these special precautions for a period of time after your surgery:

• Don’t lift anything weighing more than 10 pounds (4.5 kilograms).
• Don’t perform vigorous exercise, such as lifting heavy weights or running.
• Don’t blow your nose forcefully.
• Don’t pick your nose.
• Limit the amount of water that you drink to less than 1.6 quarts (1.5 liters) per day.
• Try not to strain at any time but especially during bowel movements.
• Limit how often you bend over, which increases pressure in your head.

Your healthcare professional may recommend that you drink plenty of water and take a stool softener to help avoid straining during bowel movements. Most people can get back to usual activities within six weeks of the surgery. Talk to your healthcare provider about when it’s OK for you to resume your usual work, exercise and other daily routines.

After transsphenoidal surgery, you may need additional treatment, such as radiation therapy, to kill any remaining tumor cells.

You may need regular blood tests to check hormone levels. This is to make sure that your pituitary gland is working as it should and your hormone levels are healthy.

Any tumor-related symptoms that you had before transsphenoidal surgery, such as vision loss, hormone dysfunction or headaches, should improve.

Prognosis after transsphenoidal surgery depends on the type of tumor that you had, the size and location of the tumor and when you had the surgery.