Although there was once a debate about the merits of transsphenoidal and transcranial surgeries, this argument is now outdated. The introduction of selective microadenomectomy by Hardy has focused the attention of the subsequent generation of neurosurgeons upon the intrasellar aspects of pituitary surgery (1). Removal of a microadenoma is unarguably better performed from below and, therefore, the number of transsphenoidal procedures wordwide has risen up dramatically since the 1960s. With this accumulation of experience, the transsphenoidal operation has been increasingly applied where it was formerly contraindicated, especially to suprasellar tumors (2-6). In our practice, trans-sphenoidal surgery is the first option for the majority of tumors at first presentation, even for those with a large suprasellar component.

There is also an improving understanding of the behavior of nonfunctioning adenomas, which constitute most of the tumors with a suprasellar component. A transsphenoidal operation for a tumor with suprasellar extension may not provide complete tumor clearance, but because most tumors grow slowly, serial scanning for surveillance of the tumor remnant or timely radiotherapy may be preferable to a craniotomy, especially in high-risk patients.

From: Management of Pituitary Tumors: The Clinicians Practical Guide, Second Edition Edited by: M. P. Powell, S. L. Lightman, and E. R. Laws, Jr. © Humana Press Inc., Totowa, NJ

Craniopharyngiomas deserve special mention. They are among the most difficult tumors to remove. Although they may be found in the intrasellar region and thereby removed relatively easily, when they extend into the third ventricle and hypothalamus they pose both difficult management and technical problems related to their invasiveness. In every pituitary surgeon's series, it is craniopharyngiomas that have the highest rate of complications, recurrence, and mortality. Seemingly successful surgery with a pristine postoperative scan can leave the patient with severe hypothalamic damage. In this chapter, we reference several approaches to craniopharyngiomas. To both the surgical editors, it seems that with increasing experience in specialization in sellar surgery, more and more operations on these tumors will be performed using the transsphenoidal procedure, particularly the extended transsphenoidal route.

Specific indications remain for the transcranial approach in a minority of cases, and these warrant separate discussion.

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