Endoscopic endonasal surgical management of giant pituitary adenomas with extension into ventricle system





giant pituitary adenoma, ventricle system, endoscopic endonasal surgery


Objective: to estimate the results of endoscopic endonasal surgical management of giant pituitary adenomas (GPAs) with extension into ventricular system (VS), to study the peculiarities of surgical techniques.

Materials and methods. 49 adult patients with GPAs with extension into VS were included in the study. The depth of research 2016-2021. This is a consecutive sampling of 1339 pituitary adenomas. GPAs with extension into VS made up 3.66% (49/1339) among all treated pituitary adenomas, and 43.4% among 113 GPAs. Distribution by gender – 18 (36.7%) women and 31 (63.3%) men. Average age was 54.1±11.3 years.

Results. The largest consecutive series of GPAs with extension into VS that underwent endoscopic endonasal surgery was analyzed. Gross total resection was achieved in 32.7% (16/49), subtotal – 42.9% (21/49), partial – 12.2% (6/49), contraindications for tumor removal were issued in 12.2% (6/49) cases, these patients underwent extended biopsy and ventriculoperitoneal shunting in 4 patients. In 67.4% (33/49) was admitted visual function improvement. In 12.2% (6/49) vision remained at preoperative level, with no visual impairment. In 20.4% (10/49) of cases, vision deteriorated immediately after surgery. Upon re-examination at 6‒8 weeks in this group, vision returned to baseline in 60% (6/10) of patients. An immunohistochemical study found that 89.8% of the tumors were hormonally inactive. There was allocated a separate group of null cell pituitary adenomas, which accounted for 18.9% of cases. ACTH, LH-FSH, GH, TTH, prolactin secreting PAs were detected in 30.6%, 24.5%, 16.3%, 8.2% and 2.0% respectively. Hypopituitarism was diagnosed in 30.6% (15/49) of patients. Diabetes insipidus was detected for the first time in the postoperative period in 12.2% (6/49) of patients. 14.3% (7/49) of the cases of postoperative cerebrospinal fluid leak were diagnosed. Meningitis developed in 8.1% (4/49). The mortality rate was 6.1% (3/49).

Conclusions. An analysis of complications in the early postoperative period found that the incidence of complications in GPAs with extension into VS was statistically significantly higher when compared to the cohort of patients who underwent endoscopic endonasal surgery for pituitary adenomas removal, indicating the complexity of this pathology. Despite the significant increase in the complexity of endoscopic interventions and still considerable threats of postoperative cerebrospinal fluid leak in the opening of the VS, we can already consider endonasal operations in the vast majority of GPAs as the method of choice. A new classification approach to the study group of GPAs was proposed. It allows us to separate the relatively low-risk and high-risk groups of high-flow intraoperative cerebrospinal fluid leak, which is directly correlated with the risks of postoperative complications and mortality in our study. In addition, we emphasize a special, although the smallest group of GPAs with extension into the third ventricle (type 3). Such cases require special attention and the decision to have ventriculoperitoneal shunting before or immediately after the removal of the tumor.


1. Tsukamoto T, Miki Y. Imaging of pituitary tumors: an update with the 5th WHO Classifications-part 1. Pituitary neuroendocrine tumor (PitNET)/pituitary adenoma. Jpn J Radiol. 2023 Aug;41(8):789-806. [CrossRef] [PubMed] [PubMed Central]

2. Chin SO. Epidemiology of Functioning Pituitary Adenomas. Endocrinol Metab (Seoul). 2020 Jun;35(2):237-242. [CrossRef] [PubMed] [PubMed Central]

3. Serioli S, Doglietto F, Fiorindi A, Biroli A, Mattavelli D, Buffoli B, Ferrari M, Cornali C, Rodella L, Maroldi R, Gasparotti R, Nicolai P, Fontanella MM, Poliani PL. Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review. Cancers (Basel). 2019 Dec 4;11(12):1936. [CrossRef] [PubMed] [PubMed Central]

4. Maiter D, Delgrange E. Therapy of endocrine disease: the challenges in managing giant prolactinomas. Eur J Endocrinol. 2014 Jun;170(6):R213-27. [CrossRef] [PubMed]

5. Iglesias P, Rodríguez Berrocal V, Díez JJ. Giant pituitary adenoma: histological types, clinical features and therapeutic approaches. Endocrine. 2018 Sep;61(3):407-421. [CrossRef] [PubMed]

6. Jamaluddin MA, Patel BK, George T, Gohil JA, Biradar HP, Kandregula S, Hv E, Nair P. Endoscopic Endonasal Approach for Giant Pituitary Adenoma Occupying the Entire Third Ventricle: Surgical Results and a Review of the Literature. World Neurosurg. 2021 Oct;154:e254-e263. [CrossRef] [PubMed]

7. Penner F, Prencipe N, Pennacchietti V, Pacca P, Cambria V, Garbossa D, Zenga F. Super Giant Growth Hormone-Secreting Pituitary Adenoma in Young Woman: From Ventricles to Nose. World Neurosurg. 2019 Feb;122:544-548. [CrossRef] [PubMed]

8. Yamada E, Akutsu H, Kino H, Tanaka S, Miyamoto H, Hara T, Matsuda M, Takano S, Matsumura A, Ishikawa E. Combined simultaneous endoscopic endonasal and microscopic transventricular surgery using a port retractor system for giant pituitary adenoma: A technical case report. Surg Neurol Int. 2021 Mar 8;12:90. [CrossRef] [PubMed] [PubMed Central]

9. Patsko YV. [Pituitary adenomas with extensive extrasellar spread] [dissertation]. Kiev (Ukraine): Romodanov Neurosurgery Institute; 1987. Russian.

10. Maidannyk OV. [Surgical treatment of giant pituitary adenomas] [dissertation]. Kyiv (Ukraine): P.L. Shupyk National Academy of Postgraduate Education; 2015. Ukrainian.

11. Guk MO. [Diagnosis and comprehensive treatment of hormonally inactive pituitary adenomas] [dissertation]. Kyiv (Ukraine): Romodanov Neurosurgery Institute; 2016. Ukrainian.

12. Eseonu CI. Surgical Considerations in Endoscopic Pituitary Dissection for the Neurosurgeon. Otolaryngol Clin North Am. 2022 Apr;55(2):389-395. [CrossRef] [PubMed]

13. McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary centers of excellence. Neurosurgery. 2012 Nov;71(5):916-24; discussion 924-6. [CrossRef] [PubMed]

14. Rizzoli P, Mullally WJ. Headache. Am J Med. 2018 Jan;131(1):17-24. [CrossRef] [PubMed]

15. Drummond J, Roncaroli F, Grossman AB, Korbonits M. Clinical and Pathological Aspects of Silent Pituitary Adenomas. J Clin Endocrinol Metab. 2019 Jul 1;104(7):2473-2489. [CrossRef] [PubMed] [PubMed Central]

16. Nishioka H, Inoshita N, Mete O, Asa SL, Hayashi K, Takeshita A, Fukuhara N, Yamaguchi-Okada M, Takeuchi Y, Yamada S. The Complementary Role of Transcription Factors in the Accurate Diagnosis of Clinically Nonfunctioning Pituitary Adenomas. Endocr Pathol. 2015 Dec;26(4):349-55. [CrossRef] [PubMed]

17. Freda PU, Beckers AM, Katznelson L, Molitch ME, Montori VM, Post KD, Vance ML; Endocrine Society. Pituitary incidentaloma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011 Apr;96(4):894-904. [CrossRef] [PubMed] [PubMed Central]

18. Renn WH, Rhoton AL Jr. Microsurgical anatomy of the sellar region. J Neurosurg. 1975 Sep;43(3):288-98. [CrossRef] [PubMed]

19. Carretta A, Zoli M, Guaraldi F, Sollini G, Rustici A, Asioli S, Faustini-Fustini M, Pasquini E, Mazzatenta D. Endoscopic Endonasal Transplanum-Transtuberculum Approach for Pituitary Adenomas/PitNET: 25 Years of Experience. Brain Sci. 2023 Jul 24;13(7):1121. [CrossRef] [PubMed] [PubMed Central]

20. Zanation AM, Carrau RL, Snyderman CH, Germanwala AV, Gardner PA, Prevedello DM, Kassam AB. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy. 2009 Sep-Oct;23(5):518-21. [CrossRef] [PubMed]

21. Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Oper Neurosurg (Hagerstown). 2007 Apr;60(4 Suppl 2):295-303; discussion 303-4. [CrossRef] [PubMed]

22. Thavaraputta S, Attaya EN, Lado-Abeal J, Rivas AM. Pneumocephalus as a Complication of Transsphenoidal Surgery for Pituitary Adenoma: A Case Report. Cureus. 2018 Aug 5;10(8):e3104. [CrossRef] [PubMed] [PubMed Central]

23. Abhinav K, Tyler M, Dale OT, Mohyeldin A, Fernandez-Miranda JC, Katznelson L. Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas. Expert Rev Endocrinol Metab. 2020 Sep;15(5):311-319. [CrossRef] [PubMed]

24. Stefanidis P, Kyriakopoulos G, Athanasouli F, Mytareli C, Τzanis G, Korfias S, Theocharis S, Angelousi A. Postoperative complications after endoscope-assisted transsphenoidal surgery for pituitary adenomas: a case series, systematic review, and meta-analysis of the literature. Hormones (Athens). 2022 Sep;21(3):487-499. [CrossRef] [PubMed]

25. Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus. 2014;37(4):E4. [CrossRef] [PubMed]

26. Jin Y, Liu X, Gao L, Guo X, Wang Q, Bao X, Deng K, Yao Y, Feng M, Lian W, Wang R, Yang Q, Wang Y, Xing B. Risk Factors and Microbiology of Meningitis and/or Bacteremia After Transsphenoidal Surgery for Pituitary Adenoma. World Neurosurg. 2018 Feb;110:e851-e863. [CrossRef] [PubMed]



How to Cite

Guk, M. O., & Ukrainets, O. V. (2023). Endoscopic endonasal surgical management of giant pituitary adenomas with extension into ventricle system. Ukrainian Neurosurgical Journal, 29(4), 13–21. https://doi.org/10.25305/unj.286547



Original articles