Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection.

PURPOSE: Surgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice. METHODS: A mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached. RESULTS: There was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured. CONCLUSIONS: Through an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed "core" steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The "optional" steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Preoperative Imaging Assessment of Patients With Suspected Nonfunctioning Pituitary Adenomas.

BACKGROUND: The authors reviewed published articles pertaining to the preoperative imaging evaluation of nonfunctioning pituitary adenomas (NFPAs) and formulated recommendations. OBJECTIVE: To provide an exhaustive review of published articles pertaining to the preoperative imaging evaluation of nonfunctioning pituitary adenomas. METHODS: The MEDLINE database was queried for studies investigating imaging for the preoperative evaluation of pituitary adenomas. RESULTS: From an initial search of 5598 articles, 122 articles were evaluated in detail and included in this article. Based on analysis of these articles, the recommendations are as follows: (1) High-resolution magnetic resonance imaging (level II) is recommended as the standard for preoperative assessment of nonfunctioning pituitary adenomas, but may be supplemented with CT (level III) and fluoroscopy (level III). (2) Although there are promising results suggesting the utility of magnetic resonance spectroscopy, magnetic resonance perfusion, positron emission tomography, and single-photon emission computed tomography, there is insufficient evidence to make formal recommendations pertaining to their clinical applications. CONCLUSION: The authors identified 122 articles that form the basis of recommendations for preoperative imaging evaluation of nonfunctioning pituitary adenomas. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_2. ABBREVIATIONS: CT, computed tomographyDWI, diffusion-weighted imagingMRI, magnetic resonance imagingNFPA, nonfunctioning pituitary adenoma.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Posttreatment Follow-up Evaluation of Patients With Nonfunctioning Pituitary Adenomas.

BACKGROUND: Nonfunctioning pituitary adenomas (NFPAs) are the most frequent pituitary tumors. Due to the lack of hormonal hypersecretion, posttreatment follow-up evaluation of NFPAs is challenging. OBJECTIVE: To create evidence-based guidelines in an attempt to formulate guidance for posttreatment follow-up in a consistent, rigorous, and cost-effective way. METHODS: An extensive literature search was performed. Only clinical articles describing postoperative follow-up of adult patients with NFPAs were included. To ascertain the class of evidence for the posttreatment follow-ups, the authors used the Clinical Assessment evidence-based classification. RESULTS: Twenty-three studies met the inclusion criteria with respect to answering the questions on the posttreatment radiologic, endocrinologic, and ophthalmologic follow-up. Through this search, the authors formulated evidence-based guidelines for radiologic, endocrinologic, and ophthalmologic follow-up after surgical and/or radiation treatment. CONCLUSION: Long-term radiologic, endocrinologic, and ophthalmologic surveillance monitoring after surgical and/or radiation therapy treatment of NFPAs to evaluate for tumor recurrence or regrowth, as well as pituitary and visual status, is recommended. There is insufficient evidence to make a recommendation on the duration of time of surveillance and its frequency. It is recommended that the first radiologic study to evaluate the extent of resection of the NFPA be performed ≥3 months after surgical intervention. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_8. ABBREVIATION: NFPA, nonfunctioning pituitary adenoma.