A triple-layer, autograft-free reconstruction strategy for skull base repair after standard endoscopic endonasal resection of pituitary adenomas.

OBJECTIVE

It is imperative to prevent cerebrospinal fluid (CSF) leakage following an endoscopic endonasal approach (EEA). This study aims to evaluate the efficacy of a simple, triple-layer reconstruction strategy for preventing CSF rhinorrhea following the standard EEA for pituitary adenomas.

METHODS

We retrospectively analyzed 213 patients who underwent a standard EEA for primary pituitary adenomas between January 2023 and March 2025. All patients received a simple reconstruction consisting of artificial dura mater placement, gelatin sponge packing, and porcine fibrin sealant sealing, without autograft harvesting. Intraoperative CSF leakage was graded according to the Kelly classification. Postoperative outcomes including CSF rhinorrhea, meningitis, and subjective olfactory changes were recorded during at least three months of follow-up. The study focused exclusively on reconstruction-related outcomes and did not assess other endpoints such as gross total resection, endocrine remission, visual recovery, and diabetes insipidus. This retrospective, single-arm case series reports preliminary outcomes of a triple-layer reconstruction strategy.

RESULTS

Intraoperative CSF leakage occurred in 97 patients (45.54%): Grade 1 in 41, Grade 2 in 45, and Grade 3 in 11. Postoperative CSF rhinorrhea developed in 3 of 213 patients (1.41%; 95% CI: 0.29%-4.25%). Among the 97 patients with intraoperative CSF leakage, the postoperative leak rate was 3.1% (3/97; 95% CI: 0.67%-9.08%). Among the 11 patients with Grade 3 intraoperative leaks, no postoperative CSF rhinorrhea was observed in this series. Meningitis occurred in 4 patients (1.88%), two of whom also had CSF rhinorrhea. Postoperative hyposmia was reported by 2 patients (0.94%), both of whom recovered normal olfaction by 6 months.

CONCLUSIONS

In this retrospective case series, the triple-layer reconstruction strategy was associated with a low postoperative CSF leak rate following standard EEA for primary pituitary adenomas. Among the small number of patients with Grade 3 intraoperative leaks in this series, no postoperative CSF rhinorrhea was observed. The technique also avoided autograft harvest and donor-site morbidity. These findings should be considered preliminary and require confirmation in prospective, controlled studies.