Other Advances

An important advance during recent years has been the realization that repeat transsphenoidal surgery represents a good option in selected patients with recurrent or persistent disease. In the past, there was a reluctance to undertake reoperations for pituitary tumors because of technical difficulties and higher complication rates (9). Consequently, radiotherapy was usually given as an alternative. Today, when undertaken by a surgeon with well-developed skills, it is a safe and effective option. Our own experience indicates that complication rates are now only minimally higher than those of initial operations. Techniques such as the transnasal septal pushover, which obviates difficult septal dissection and provides safe access through a previously operative field, have contributed to this success (11). Neuronavigational techniques and endoscopic assistance have also added to the safety.

A final innovation has been the development of the extended transsphenoidal approach, which broadens the range of transsphenoidal surgery, to include lesions previously believed accessible only to transcranial approaches. Not only does this include adenomas with unusual configurations but also other mass lesions, particularly craniopharyngiomas with suprasellar, retrosellar, or anterosellar dispositions. This approach, which is as much a conceptual advance as it is technical, involves greater resection of skull base from below and permits removal of genuine intrac-ranial pathology via the transsphenoidal route. In doing so, it pushes the limits of transsphenoidal surgery to a new frontier (12).

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