Transsphenoidal reoperations for removal of pituitary adenomas: rhinological management and timing of reoperation.

Transsphenoidal reoperation of pituitary adenomas remain a difficult surgical procedure even with skilful microsurgical techniques. This paper retrospectively analysed how to overcome such difficult factors as absent normal surgical landmarks and an adhesive field. For residual or recurrent adenomas, transsphenoidal reoperations were carried out 14 times in 12 patients. Reasons for reoperations were intentionally multistaged operations in 10 cases, regrowth in three and apoplexy in one. In the first operation, we tried to preserve or restore as many anatomic landmarks as possible. Overly aggressive procedures causing cerebrospinal fluid leakage were avoided. In the three second reoperations within 3 months, a transnasal approach was used. In the other eight situations, between 4 and 119 months, transnasal approach in five, and transseptal approach in three, were used retrospectively. In two patients with fibrous adenomas, reoperations were carried out 4 and 12 months after the first. Magnetic resonance imaging (MRI) evaluation is essential to confirm the tumour descent toward or into pituitary fossa. Timing of the reoperation needs to be individualized depending on MRI findings. Trauma to the nasal mucosa and a narrower operative field became more frequent in reoperations 4 months or later. To obtain a surgical field wide enough to manipulate an ultrasonic aspirator for fibrous adenomas, removal of bony structures at the nasal cavity on the surgical corridor is useful. These rhinological preparations in the first and subsequent operations along with a selection of timing of reoperation are important to gain easier access for tumour removal and in avoidance of surgical complications. Copyright 1999 Harcourt Publishers Ltd.