title: Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas.
abstract: OBJECTIVE
  Craniopharyngiomas have traditionally represented a challenge for open transcranial or transsphenoidal microscopic neurosurgery because of their anatomical location and proximity to vital neurovascular structures. The extended endoscopic endonasal transsphenoidal approach has been more recently developed as a potentially surgically aggressive, yet minimal access, alternative. To gain a more comprehensive assessment of the benefits and limitations of the various approaches to resection of craniopharyngiomas, we performed a systematic review of the available published reports after endoscope-assisted endonasal approaches and compared their results with transsphenoidal purely microscope-based or transcranial microscope-based techniques.
  
  
  METHODS
  We performed a MEDLINE search of the modern literature (1995-2010) to identify open and endoscopic surgical series for pediatric and adult craniopharyngiomas. Comparisons were made for patient and tumor characteristics as well as extent of resection, morbidity, and visual outcome. Statistical analyses of categorical variables were undertaken by the use of χ(2) and Fisher exact tests with post-hoc Bonferroni analysis to compare endoscopic, microsurgical transsphenoidal, and transcranial approaches.
  
  
  RESULTS
  Eighty eight studies, involving 3470 patients, were included. The endoscopic cohort had a significantly greater rate of gross total resection (66.9% vs. 48.3%; P < 0.003) and improved visual outcome (56.2% vs. 33.1%; P < 0.003) compared with the open cohort. The transsphenoidal cohort had similar outcomes to the endoscopic group. The rate of cerebrospinal fluid leakage was greater in the endoscopic (18.4%) and transsphenoidal (9.0%) than in the transcranial group (2.6%; P < 0.003), but the transcranial group had a greater rate of seizure (8.5%), which did not occur in the endonasal or transsphenoidal groups (P < 0.003).
  
  
  CONCLUSIONS
  The endoscopic endonasal approach is a safe and effective alternative for the treatment of certain craniopharyngiomas. Larger lesions with more lateral extension may be more suitable for an open approach, and further follow-up is needed to assess the long-term efficacy of this minimal access approach.
authors.affiliation: Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
authors.forename: Ricardo J
authors.initials: RJ
authors.lastname: Komotar
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Daniel M S
authors.initials: DM
authors.lastname: Raper
authors.forename: Vijay K
authors.initials: VK
authors.lastname: Anand
authors.forename: Theodore H
authors.initials: TH
authors.lastname: Schwartz
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D015331:Cohort Studies; D003397:Craniopharyngioma / Q000150:complications / Q000601:surgery*; D004724:Endoscopy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D009296:Nasal Cavity / Q000601:surgery*; D009493:Neurosurgery; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D010911:Pituitary Neoplasms / Q000150:complications / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012640:Seizures / Q000209:etiology; D013100:Sphenoid Bone / Q000601:surgery*; D016896:Treatment Outcome; D014786:Vision Disorders / Q000209:etiology / Q000601:surgery; D014785:Vision, Ocular / Q000502:physiology; D055815:Young Adult