Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations.
OBJECT.: While transsphenoidal surgery is associated with low morbidity, the degree to which morbidity increases after reoperation remains unclear. The authors determined the morbidity associated with repeat versus initial transsphenoidal surgery after 1015 consecutive operations.


METHODS
The authors conducted a 5-year retrospective review of the first 916 patients undergoing transsphenoidal surgery at their institution after a pituitary center of expertise was established, and they analyzed morbidities.


RESULTS
The authors analyzed 907 initial and 108 repeat transsphenoidal surgeries performed in 916 patients (9 initial surgeries performed outside the authors' center were excluded). The most common diagnoses were endocrine inactive (30%) or active (36%) adenomas, Rathke's cleft cysts (10%), and craniopharyngioma (3%). Morbidity of initial surgery versus reoperation included diabetes insipidus ([DI] 16% vs 26%; p = 0.03), postoperative hyponatremia (20% vs 16%; p = 0.3), new postoperative hypopituitarism (5% vs 8%; p = 0.3), CSF leak requiring repair (1% vs 4%; p = 0.04), meningitis (0.4% vs 3%; p = 0.02), and length of stay ([LOS] 2.8 vs 4.5 days; p = 0.006). Of intraoperative parameters and postoperative morbidities, 1) some (use of lumbar drain and new postoperative hypopituitarism) did not increase with second or subsequent reoperations (p = 0.3-0.9); 2) some (DI and meningitis) increased upon second surgery (p = 0.02-0.04) but did not continue to increase for subsequent reoperations (p = 0.3-0.9); 3) some (LOS) increased upon second surgery and increased again for subsequent reoperations (p < 0.001); and 4) some (postoperative hyponatremia and CSF leak requiring repair) did not increase upon second surgery (p = 0.3) but went on to increase upon subsequent reoperations (p = 0.001-0.02). Multivariate analysis revealed that operation number, but not sex, age, pathology, radiation therapy, or lesion size, increased the risk of CSF leak, meningitis, and increased LOS. Separate analysis of initial versus repeat transsphenoidal surgery on the 2 most common benign pituitary lesions, pituitary adenomas and Rathke's cleft cysts, revealed that the increased incidence of DI and CSF leak requiring repair seen when all pathologies were combined remained significant when analyzing only pituitary adenomas and Rathke's cleft cysts (DI, 13% vs 35% [p = 0.001]; and CSF leak, 0.3% vs 9% [p = 0.0009]).


CONCLUSIONS
Repeat transsphenoidal surgery was associated with somewhat more frequent postoperative DI, meningitis, CSF leak requiring repair, and greater LOS than the low morbidity characterizing initial transsphenoidal surgery. These results provide a framework for neurosurgeons in discussing reoperation for pituitary disease with their patients.
Department of Neurosurgery and The California Center for Pituitary Disorders, University of California, San Francisco, California.
Arman
A
Jahangiri
Jeffrey
J
Wagner
Sung Won
SW
Han
Corinna C
CC
Zygourakis
Seunggu J
SJ
Han
Mai T
MT
Tran
Liane M
LM
Miller
Maxwell W
MW
Tom
Sandeep
S
Kunwar
Lewis S
LS
Blevins
Manish K
MK
Aghi
D000236:Adenoma / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020863:Central Nervous System Cysts / Q000601:surgery; D065634:Cerebrospinal Fluid Leak; D002559:Cerebrospinal Fluid Rhinorrhea / Q000209:etiology; D002648:Child; D002675:Child, Preschool; D003919:Diabetes Insipidus / Q000209:etiology; D005260:Female; D006801:Humans; D007010:Hyponatremia / Q000209:etiology; D007902:Length of Stay; D008297:Male; D008581:Meningitis / Q000209:etiology; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D010900:Pituitary Diseases / Q000601:surgery; D010902:Pituitary Gland / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000601:surgery; D011183:Postoperative Complications / Q000209:etiology*; D012086:Reoperation; D013100:Sphenoid Bone / Q000601:surgery*; D055815:Young Adult
DI = diabetes insipidus; LOS = length of stay; morbidity; oncology; pituitary surgery; reoperation; transsphenoidal surgery