Pituitary Innovation and Teaching

Types of treatment

Introduction || Types || Transphenoidal || Success rate

Surgery

Illustration of pituitary surgery Surgery is often the best treatment option for patients with a pituitary tumour who are healthy enough to have surgery and any of the following:

  • whose tumour is putting pressure on or damaging the nerves of their eyes (optic nerves or chiasm)
  • whose tumour is making too much hormone, such as growth hormone or ACTH
  • whose prolactinoma is not responding to medicine
  • whose tumour is growing
  • whose diagnosis is not clear from other tests
  • whose tumour has come back after surgery or is causing a leakage of brain fluid after surgery

Goals

The goals of surgery are to:

  1. diagnose the type of tumour
  2. reduce pressure on important structures like the nerves of the eyes
  3. remove as much of the tumour as possible (this reduces the chance of the tumour coming back)
  4. help reduce symptoms like headaches, visual loss, and high or low hormone levels
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Types of surgery

There are two types of surgery for removing pituitary tumours: “transphenoidal” surgery or a “craniotomy”.

Transphenoidal surgery is done through the nose (see Figure 7). This method helps the surgeon access the base of the brain where pituitary tumours usually are.

A craniotomy is a type of surgery where the surgeon opens a window in the skull to access the tumour, instead of through the nose. This may be the best type of surgery if the tumour:

  • is large
  • is of a certain type
  • goes off to the sides
  • lies deeper in the brain
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How does transphenoidal surgery work?

  1. A general anesthetic to put the patient asleep is required.

  2. During surgery, a small telescope with a tiny video camera at the end called an “endoscope” is guided through the nose and nostril passages to the tumour.

  3. The surgeon will remove small pieces of bone to expose the pituitary gland and the tumour.

  4. The surgeon will then remove the tumour. If the tumour is too large or if it is stuck to important structures in the brain, it may not be possible to remove the whole tumour.

  5. The bones are usually replaced with a tiny amount of  biological glue and can be covered with a layer of the nasal cavity lining called mucosa.

  6. If there is a leakage of brain water called cerebrospinal fluid, some small pieces of fat or tissue that covers the thigh muscle will be taken from the side of the thigh or lower tummy to close the surgical area.

  7. The surgeon will check for any leaking from your nose. Occasionally, if there is a large amount of cerebrospinal fluid (also called CSF) leakage there is a risk of developing a serious infection called meningitis. If this fluid is leaking a lot during or after surgery from your nose, the surgeon may place a drain in the lower back. This drain will allow the CSF to drain out into a bag for a few days. Draining the cerebrospinal fluid will relieve the pressure in your nose and allow your incision to heal.

  8. Once the surgical area is sealed, two small plastic sheets are put in to the nose to prevent the growth of scar tissue. These sheets will be removed by the ENT surgeon two to three weeks after surgery.

  9. At the end of the surgery, the nostrils are packed with Vaseline gauze or a sponge to prevent nose bleeding.

  10. The surgery usually lasts a total of three to six hours but it depends on the tumour size, tumour extent, texture, and whether scar tissue exists.

What is the success rate?

The success rate of surgery for all kinds of tumours depends on the size and extent of the tumour, texture (firm or soft), and type of tumour. In most cases, if vision is impaired but still present before surgery, there is a good chance that the vision will be preserved and some chance of improvement, even if the tumour is large. If the tumour extends around the artery, tumour will usually remain after surgery. In the case of functioning tumours like Cushing’s disease, the success rate is better if the tumour is visible on MRI and localized. Tumours that are invading structures around the pituitary gland, are growing rapidly or are regrowing have a lower chance of success.

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Page last updated: November 22, 2016