2025 Proffered Presentations
S123: ENDOSCOPIC ENDONASAL PITUITARY TRANSPOSITION FOLLOWED BY POSTERIOR CLINOIDECTOMY TO ACCESS THE RETROSELLAR AND RETROINFUNDIBLAR SPACE: A COMPARISON OF ENDOCRINOLOGICAL OUTCOMES BETWEEN EXTRADURAL, INTERDURAL AND INTRADURAL TECHNIQUES
Maria José Pachón-Londoño, MD; Vita A Olson, BA; Maged T Ghoche, MD; Estefana Bcharah; Abhijith Bathini, MD; Charbel Moussalem, MD; Devi P Patra, MD; Bernard R Bendok, MD, MSCI; Mayo Clinic
Background: Pathologies of the retrosellar space, the interpeduncular and the prepontine cistern represent a challenge due to presence of critical neurovascular structures in the surgical corridors to access them. Expanded endoscopic endonasal approaches for pituitary transposition followed by posterior clinoidectomy have been described as alternative surgical corridors to transcranial approaches. In this study we aimed to review the literature and compare post operative outcomes in patients undergoing pituitary transposition through three different techniques; extradural, intradural and interdural.
Methods: We report a systematic review of the literature according to PRISMA 2020 Guidelines. We searched PubMed, Web of Science, Embase and Scopus. Articles reporting post operative outcomes in patients undergoing pituitary transposition or hemitransposition through extradural, intradural or interdural corridors followed by posterior clinoidectomy were included. General linear models using R software were performed to analyze the statistical association between the technique used and the post operative outcomes.
Results: Sixteen studies encompassing 100 patients with 13 types of vascular and neoplastic lesions were included in our final analysis. 48 patients underwent extradural pituitary transposition, while the intradural and interdural technique were performed in 17 and 35 patients, respectively. Sacrifice of at least one Inferior Hypophyseal Artery (IHA) was associate with the intradural (58%) and interdural (91%) group compared to the extradural group in which none of the patients required sacrifice of the IHA (p <0.01). When IHA sacrifice was performed, it was most commonly bilateral sacrifice (p <0.05). Stable anterior pituitary function (Intact or not worsened) was not significantly different in the three groups (p = 0.40). Transient diabetes insipidus (DI) was not significantly associated with the choice of pituitary transposition technique (p = 0.07). Permanent DI was present in 28% of patients in the extradural group and 25% and 21% of patients in the intradural and interdural technique, respectively (p < 0.05). No injury of the inferior carotid artery (ICA) was reported in any of the patients.
Discussion: Different factors have been proposed to affect endocrinological outcomes after pituitary transposition such as blood flow interruption from the superior and inferior hypophyseal arteries, surgical manipulation of the pituitary capsule and the stalk, and disruption of the venous outflow from the gland. Our results indicate that even though interdural and intradural techniques are associated with the sacrifice of at least one of the IHAs at a higher rate compared to extradural transposition. These findings do not translate into increased anterior pituitary dysfunction in the groups where the IHA is sacrificed. Indicating the need for further research on prioritized superior hypophyseal artery preservation over inferior hypophyseal artery. Limitations of this review include the small sample size and publication bias from individual case reports.
Conclusion: Extradural, interdural and intradural techniques for pituitary transposition represent alternative corridors to reach the retrosellar and the retro infundibular space. These approaches have shown to be safe with low rates new or worsened pituitary dysfunction. However, further clinical studies are needed to elucidate the post operative outcomes when compared to transcranial approaches.