title: Combined simultaneous transcranial and transsphenoidal resection of large-to-giant pituitary adenomas.
abstract: BACKGROUND
  While large-to-giant pituitary adenomas (PAs) may be safely removed by experienced surgeons through a single route, the procedure is technically challenging. We present the outcome of a simultaneous combined transcranial and transsphenoidal approach and discuss its applications.
  
  
  METHODS
  A retrospective review was conducted on 12 consecutive patients. Surgical complications, visual and endocrinological functions, and tumour control were reviewed.
  
  
  RESULTS
  There were four men and eight women, with a mean age of 47.6 years. All but one patient had non-functioning PAs. The mean tumour height was 4.1 cm (range: 2.3-5.5). The predominant presenting symptoms were visual field loss in eight patients, headache in three patients and mental confusion in one patient. There was no operative mortality. Post-operative cerebrospinal fluid leakage occurred in one patient. Five of the eight patients who presented with visual field loss achieved full recovery, and three had partial improvement. Two patients developed permanent diabetes insipidus after surgery. Panhypopituitarism occurred in one patient. Gross total removal (GTR) was achieved in five, and subtotal removal (STR) in seven patients. Seven patients received post-operative external irradiation. All patients who had GTR remained tumour-free and all those with STR had stable diseases after a mean follow-up period of 53.1 months (range: 14.1-92.1).
  
  
  CONCLUSIONS
  The simultaneous 'above and below' approach is a safe and effective surgical strategy for large-to-giant PAs, particularly when expertise in endoscopic transsphenoidal surgery is unavailable. Its use, however, should be limited to a carefully selected group of patients, and tailored to individual user's expertise and experience.
authors.affiliation: Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China. gilberto@hkucc.hku.hk
authors.forename: Gilberto Ka Kit
authors.initials: GK
authors.lastname: Leung
authors.forename: Hing Yu
authors.initials: HY
authors.lastname: Law
authors.forename: Kwun Ngai
authors.initials: KN
authors.lastname: Hung
authors.forename: Yiu Wah
authors.initials: YW
authors.lastname: Fan
authors.forename: Wai Man
authors.initials: WM
authors.lastname: Lui
mesh_terms: D000328:Adult; D000368:Aged; D002559:Cerebrospinal Fluid Rhinorrhea / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D003399:Craniotomy / Q000295:instrumentation / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007016:Hypophysectomy / Q000295:instrumentation / Q000379:methods*; D007018:Hypopituitarism / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D010911:Pituitary Neoplasms / Q000473:pathology / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D012189:Retrospective Studies; D013100:Sphenoid Bone / Q000601:surgery*; D016896:Treatment Outcome; D014786:Vision Disorders / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control