Department of Neurosurgery, University of Ulm, Ludwig-Heilmeyerstr. 2, 89312, Günzburg, Germany.
Endokrinologiezentrum Ulm, Bahnhofplatz 7, 89073, Ulm, Germany.
Neurosurg Rev. 2019 Sep;42(3):737-743. doi: 10.1007/s10143-019-01102-7. Epub 2019 Apr 4.
The use of intraoperative MRI (iMRI) increases extent of resection in transsphenoidal pituitary surgery. Microsurgical and endoscopic techniques have been established as equal and standard surgical methods. The object of the current study was to evaluate the additional value of iMRI for resection of invasive pituitary adenomas. We conducted a retrospective monocenter study of all consecutive patients treated with invasive pituitary adenomas graded as Knosp III-IV at our department after the introduction of iMRI in 2008. Out of 315 transsphenoidal surgeries for pituitary adenomas, 111 met the criteria for analysis. Patients treated with endoscopic or microsurgical technique were included. iMRI was performed at surgeons' discretion, when maximal safe resection was assumed. Detailed volumetric tumor analysis using semiautomatic segmentation software (Brainlab Elements) before surgery, during surgery, and after surgery was performed. Additionally, demographic data, additional resection, endocrinological outcome as well as complications were evaluated. Postoperative tumor volume as measured in the follow-up MRI 3 months after surgery was significantly lower compared with intraoperative tumor volume (p < 0.001). The difference was statistically significant for both surgical techniques (p < 0.001). No significant difference was found between both techniques in intraoperative and postoperative tumor volume (p = 0.395 and p = 0.329 respectively). Additional tumor resection was performed in 56 cases (50.5%). We found no significant difference between microsurgical and endoscopic techniques regarding additional resection after iMRI (p = 0.512). New diagnosed permanent diabetes insipidus was found in 10 patients (10.5%, 10/95). New hypopituitarism was seen in 22.1% (21/95) cases and according to multivariate logistic regression was significantly associated with microsurgical technique (p = 0.035). Visual improvement was achieved in 76.8% (N = 53/69, p < 0.001) of patients with visual impairment before surgery. Revision surgery as the consequence of cerebrospinal fistula was performed in eight cases (7.2%). Meningitis was documented in three patients (2.7%). One patient died as a consequence of intraoperative vascular injury. Intraoperative MRI after maximal safe resection significantly improves the overall extent of resection in invasive pituitary adenomas independent of the surgical technique employed. Simultaneously, iMRI-assisted transsphenoidal surgery results in excellent visual recovery with low-risk profile for surgical complications for both endoscopic as well as microsurgical technique. Endoscopic technique might be related to the lower incidence of new hypopituitarism after surgery.
术中磁共振成像(iMRI)增加了经蝶窦垂体手术的切除范围。显微外科和内镜技术已被确立为同等和标准的手术方法。本研究的目的是评估 iMRI 对侵袭性垂体腺瘤切除的附加价值。我们对 2008 年引入 iMRI 后在我科接受治疗的所有 Knosp III-IV 级侵袭性垂体腺瘤连续患者进行了回顾性单中心研究。在 315 例垂体腺瘤经蝶窦手术中,有 111 例符合分析标准。纳入接受内镜或显微技术治疗的患者。当假设最大安全切除时,iMRI 由外科医生自行决定进行。在术前、术中和术后使用半自动分割软件(Brainlab Elements)对肿瘤进行详细的容积分析。此外,还评估了人口统计学数据、额外切除、内分泌学结果以及并发症。术后 3 个月的随访 MRI 测量的肿瘤体积明显低于术中肿瘤体积(p<0.001)。两种手术技术的差异均具有统计学意义(p<0.001)。两种技术在术中肿瘤体积和术后肿瘤体积方面均无显著差异(p=0.395 和 p=0.329)。56 例(50.5%)患者进行了额外肿瘤切除。我们发现 iMRI 后显微外科和内镜技术的额外切除之间没有显著差异(p=0.512)。新诊断的永久性尿崩症 10 例(10.5%,10/95)。新发生的垂体功能减退症 22.1%(21/95),多变量逻辑回归显示与显微外科技术显著相关(p=0.035)。术前存在视力障碍的 69 例患者中有 76.8%(N=53/69,p<0.001)视力得到改善。8 例(7.2%)因脑脊液漏而行翻修手术。3 例(2.7%)患者发生脑膜炎。1 例患者因术中血管损伤死亡。最大安全切除后进行术中磁共振成像可显著提高侵袭性垂体腺瘤的总体切除范围,与所使用的手术技术无关。同时,iMRI 辅助经蝶窦手术可实现极好的视力恢复,内镜和显微技术的手术并发症风险低。内镜技术可能与术后新发生的垂体功能减退症发生率较低有关。