New developments in pituitary surgical techniques.

Despite ongoing advances in the pharmacological, radiotherapeutic and endocrine management of pituitary tumours, surgery remains the therapy of choice for the large majority of these lesions. As surgical efficacy is now being judged by more rigorous technical standards and by more stringent endocrine criteria than ever before, such scrutiny has only served to reinforce the fundamental role of surgery in pituitary tumour management. With the revival of the trans-sphenoidal approach, together with its ongoing technical evolution during the past three decades, pituitary tumours have emerged as eminently treatable lesions, with trans-sphenoidal microsurgery affording long-term, high-quality survival in many patients. Pituitary surgery is, however, not without limitation or liability. Even in experienced hands, endocrine and/or oncological remission is not uniformly achieved. Moreover, of those patients in whom such 'cures' can be induced, the durability of the response is not absolute, as tumour recurrence will continue to threaten a small but significant proportion of patients over time. Finally, and notwithstanding the fact that trans-sphenoidal surgery remains one of the safest procedures in contemporary, neurosurgical practice, complications can occur, some of which can be associated with significant morbidity and, on rare occasions, mortality. Clearly, there continue to be areas in need of improvement, and it has been in response to these limitations of contemporary pituitary surgery that neurosurgeons have sought to develop alternative strategies to improve surgical outcome. As a result, a variety of important innovations have been introduced during recent years. Among others, the most important and effective of these have been the application of neuronavigational techniques, trans-sphenoidal endoscopy and intraoperative MR resection control to the standard trans-sphenoidal approach to pituitary tumours. Whereas some advances are conceptual and others are technical, all are helping to push the limits of pituitary surgery to new frontiers of efficacy and safety. In this chapter, the current state of the art of pituitary surgery is reviewed along with those important new developments that, in the foreseeable future, hope to improve the quality of surgical care available to the pituitary tumour patient.