Endoscopic Vascular Decompression of the Trigeminal Nerve

Indian Neurosurgeons at the Forefront: A Comprehensive Exploration of their Pioneering Contributions to Neuroendoscopy

This article delves into the profound impact of Indian neurosurgeons on the expansive canvas of neuroendoscopy. By scrutinizing their trailblazing research, innovations, new surgical techniques, and relentless dedication to education and training, we aim to unravel the intricacies of their influence on a global scale. The review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, conducts a comprehensive analysis of the literature related to neuroendoscopy contributed by Indian neurosurgeons. The exploration covers a spectrum of achievements, ranging from pioneering research and innovations to complication avoidance, neuroendoscopic training, and global recognition. Despite challenges, Indian neurosurgeons continue to lead the way in shaping the future of neuroendoscopy, ensuring better patient outcomes and improved quality of life. Many Indian neurosurgeons have contributed significantly to the development of neuroendoscopy in India. Prof. YR Yadav's contributions stand significant in the form of research articles and publications on almost all subjects on neuroendoscopy, the textbook on neuroendoscopy, popularizing neuroendoscopy by starting the first university-certified neuroendoscopy fellowship training program in India, describing many innovative techniques/first report of endoscopic techniques and conducting regular endoscopic workshops in his institutions and other major cities of India.

Fully Endoscopic Microvascular Decompression for Trigeminal Neuralgia: Technical Note Describing a Single-Center Experience

BACKGROUND

Microscopic microvascular decompression (MVD) of the trigeminal nerve is the gold standard surgical treatment for medically refractory classical trigeminal neuralgia. Endoscopy has significantly advanced surgery and provides enhanced visualization of the cerebellopontine angle and its critical neurovascular structures. We present our initial experience of fully endoscopic microvascular decompression (e-MVD).

METHODS

This retrospective case series investigated e-MVD performed from September 2016 to February 2020 at a single institution. Clinical data including presenting symptoms, medications, operative findings, postoperative complications, and outcomes were recorded. The 5-point Barrow Neurological Institute (BNI) pain intensity score was used to quantify patients' pain relief.

RESULTS

During the study period, 25 patients with trigeminal neuralgia (10 males, 15 females; mean [SD] age = 63 [10.4] years) underwent e-MVD. All patients had a preoperative BNI score of V. The left side was affected in 15 patients. Complications occurred in 2 patients: both experienced hearing loss, and one experienced transient facial weakness 7 days after surgery. The facial weakness had resolved by the last follow-up. All patients were completely pain-free (BNI score I) immediately postoperatively. On latest follow-up, 22 patients have remained pain-free, and 3 patients have recurrent pain that is being controlled with medication (BNI score III).

CONCLUSIONS

Our study demonstrated that e-MVD is a safe, possibly effective method of performing MVD with the added benefit of improved visualization of the operative field for the operating surgeon and the surgical team. Larger prospective studies are required to evaluate whether performing e-MVD confers any additional benefits in long-term clinical outcome of patients with trigeminal neuralgia.

Complication Rates During Endoscopic Microvascular Decompression Surgery Are Low With or Without Petrosal Vein Sacrifice

OBJECTIVE

Endoscopic-microvascular decompression (E-MVD) is a well-described treatment for trigeminal neuralgia (TGN), but there has been debate on the safety of intraoperative sacrifice of the petrosal vein (PV) due to concern for subsequent venous insufficiency. Our objective was to investigate the risk of PV sacrifice during E-MVD in TGN and subsequent postoperative complications and pain outcomes.

METHODS

5 five-year review yielded 201 patients who underwent MVD for TGN. PV sacrifice, vascular compressive anatomy, and postoperative complications attributable to venous insufficiency were analyzed. Preoperative and postoperative pain outcomes were analyzed.

RESULTS

PV was sacrificed in 118 of 201 (59%) of patients, with 43 of 201 (21%) patients undergoing partial sacrifice versus 75 of 201 (37%) with complete sacrifice. No cases of venous infarction, cerebellar swelling, or fatal complications were noted in either cohort. Non-neurologic complications occurred in 1.69% (2 of 118) of patients with PV sacrifice and 0% (0 of 83) of patients with PV preservation. Neurologic deficits (facial palsy, conductive hearing loss, gait instability, memory deficit) occurred in equal proportions in PV preservation and sacrifice groups (2.41% vs. 1.69%) Overall, 87.3% (145 of 166) patients reported their pain as "very much improved" or "much improved" at 1 month, and no difference between groups was identified.

CONCLUSIONS

This study did not find higher complication rates in patients undergoing petrosal vein sacrifice during E-MVD for trigeminal neuralgia. In this series where petrosal vein was sacrificed only 59% of the time, it appears to be a safe technique, but larger studies will be needed to determine true incidence of complications after PV sacrifice.

Endoscopic versus open microvascular decompression for trigeminal neuralgia: a systematic review and comparative meta-analysis

OBJECTIVE

Microvascular decompression (MVD) is commonly used in the treatment of trigeminal neuralgia (TN) with positive clinical outcomes. Fully endoscopic MVD (E-MVD) has been proposed as an effective minimally invasive alternative, but a comparative review of the two approaches has not been conducted. The authors performed a meta-analysis of studies, comparing patient outcome rates and complications for the open versus the endoscopic technique.

METHODS

The PubMed/MEDLINE and Ovid databases were searched for studies published from database inception to 2017. The search terms used included, but were not limited to, "open microvascular decompression," "microvascular decompression for trigeminal neuralgia," and "endoscopic decompression for trigeminal neuralgia." Criteria for inclusion of studies in the meta-analysis were established as follows: adult patients, clinical studies with ≥ 10 patients (excluding case studies to obtain a higher volume of outcome rates), utilization of open MVD or E-MVD to treat TN, craniotomy and retrosigmoid incision, English-language studies, and articles that listed pain relief outcomes (complete, very good, partial, or absent), recurrence rate (number of patients), and complications (paresis, hearing loss, CSF leakage, cerebellar damage, infection, death). Relevant references from the chosen articles were also included.

RESULTS

From a larger pool of 1039 studies, 23 articles were selected for review: 13 on traditional MVD and 10 on E-MVD. The total number of patients was 6749, of which 5783 patients (and 5802 procedures) had undergone MVD and 993 patients (and procedures) had undergone E-MVD. Analyzed data included postoperative pain relief outcome (complete or good pain relief vs partial or no pain relief), and rates of recurrence and complications including facial paralysis, weakness, or paresis; hearing loss; auditory and facial nerve damage; cerebrospinal fluid leakage; infection; cerebellar damage; and death.Good pain relief was achieved in 81% of MVD patients and 88% of E-MVD patients, with a mean recurrence rate of 14% and 9%, respectively. Average rates of reported complications were statistically lower in E-MVD than in MVD approaches, including facial paresis or weakness, hearing loss, cerebellar damage, infection, and death, whereas cerebrospinal fluid leakage was similar. The overall incidence of complications was 19% for MVD and 8% for E-MVD.

CONCLUSIONS

The reviewed literature revealed similar clinical outcomes with respect to pain relief for MVD and E-MVD. The recurrence rate was lower in E-MVD studies, though not significantly so, and the incidence of complications, notably facial paresis and hearing loss, were statistically higher for MVD than for E-MVD. Based on these results, the use of endoscopy to perform MVD for TN appears to offer at least as good a surgical outcome as the more commonly used open MVD, with the possible added advantages of having a shorter operative time, smaller craniotomy, and lower recurrence rates. The authors advise caution in interpreting these data given the asymmetry in the sample size between the two groups and the relative novelty of the E-MVD approach.

Endoscopic versus microscopic microvascular decompression for trigeminal neuralgia: equivalent pain outcomes with possibly decreased postoperative headache after endoscopic surgery

OBJECTIVE

Endoscopic surgery has revolutionized surgery of the ventral skull base but has not yet been widely adopted for use in the cerebellopontine angle. Given the relatively normal anatomy of the cerebellopontine angle in patients with trigeminal neuralgia (TN), the authors hypothesized that a fully endoscopic microvascular decompression (E-MVD) might provide pain outcomes equivalent to those of microscopic MVD (M-MVD) but with fewer complications.

METHODS

The authors conducted a single-institution, single-surgeon retrospective study with patients treated in the period of 2006–2013. Before surgery, all patients completed a questionnaire that included a validated multidimensional pain-outcome tool, the Penn Facial Pain Scale (PFPS, formerly known as Brief Pain Inventory–Facial), an 11-point scale that measures pain intensity, interference with general activities of daily living (ADLs), and facial-specific ADLs. Using a standardized script, independent research assistants conducted follow-up telephone interviews.

RESULTS

In total, 167 patients were available for follow-ups (66.5% female; 93 patients underwent M-MVD and 74 underwent E-MVD). Preoperative characteristics (i.e., TN classification, PFPS components, and medication use) were similar for the 2 surgical groups except for 2 variables. Patients in the M-MVD group had slightly higher incidence of V3 pain, and the 2 groups differed in the date of surgery and hence in the length of follow-up (2.4 years for the M-MVD group and 1.3 years for the E-MVD group, p < 0.05). There was a trend toward not finding neurovascular conflict at the time of surgery more frequently in the M-MVD than in the E-MVD group (11% vs 7%, p = 0.052). Internal neurolysis was more often performed in the E-MVD group (26% vs 7%, p = 0.001). The 2 groups did not significantly differ in the length of the MVD procedure (approximately 2 hours). Self-reported headaches at 1 month postoperatively were present in 21% of the patients in the M-MVD group versus 7% in the E-MVD group (p = 0.01). Pain outcomes at the most recent followup were equivalent, with patients reporting a 5- to 6-point (70%–80%) improvement in pain intensity, a 5-point (85%) improvement in pain interference with ADLs, and a 6-point (85%) improvement in interference with facial-specific ADLs. Actuarial freedom from pain recurrence was equivalent in the 2 groups, with 80% pain control at 3 years.

CONCLUSIONS

Both the fully endoscopic MVD and the conventional M-MVD appear to provide patients with equivalent pain outcomes. Complication rates were also similar between the groups, with the exception of the rate of headaches, which was significantly lower in the E-MVD group 1 month postoperatively.

Neuroendoscopy - Is it safe?

BACKGROUND

The effect of heat in endoscopic instruments used for laparoscopy and hysteroscopy has been well-studied. Reports of thermal injury from nasal endoscopes have also been reported. However, there are no experimental studies, which have objectively documented and provided recommendations for safe use of endoscopes in neurosurgery.

OBJECTIVES

To study the heat generated at the tip of the endoscope and the subsequent thermal damage caused to a cotton drape placed in proximity, by varying the intensity of light delivered through different optical cables, ambient (operating room) temperatures and working distances.

MATERIALS AND METHODS

The study was carried out in the operation theater using a 300 watt xenon light source connected to the endoscope with 3.5 mm and 4.8 mm optical cables. A digital thermometer was used to record the heat generated at the tip of the endoscope.

RESULTS

The heat generated at the tip of the endoscope reached its peak in the first 6 min and attained a plateau at 15 min after turning on a light source of 60% intensity. Thermal injury to the cotton drape took a longer time with a 3.8 mm cable compared with 4.8 mm cable. The heat generated at the tip of the endoscope, and thereby the thermal injury caused was found to be lower when the ambient temperature was close to 20°C.

CONCLUSIONS

Complications related to thermal injuries caused by heat generated at the tip of an endoscope can be reduced by using a smaller diameter cable, light intensity of 60%, increasing the working distance (as permissible), reducing the time spent for dissection while keeping the endoscope very close to the target and lowering the ambient temperature to 20°C.

Trigeminal Neuralgia

Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing, and recurrent pain within one or more branches of the trigeminal nerve. Type 1 as intermittent and Type 2 as constant pain represent distinct clinical, pathological, and prognostic entities. Although multiple mechanism involving peripheral pathologies at root (compression or traction), and dysfunctions of brain stem, basal ganglion, and cortical pain modulatory mechanisms could have role, neurovascular conflict is the most accepted theory. Diagnosis is essentially clinically; magnetic resonance imaging is useful to rule out secondary causes, detect pathological changes in affected root and neurovascular compression (NVC). Carbamazepine is the drug of choice; oxcarbazepine, baclofen, lamotrigine, phenytoin, and topiramate are also useful. Multidrug regimens and multidisciplinary approaches are useful in selected patients. Microvascular decompression is surgical treatment of choice in TN resistant to medical management. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation procedures. Partial sensory root sectioning is indicated in negative vessel explorations during surgery and large intraneural vein. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict and entire root from pons to ganglion including ventral aspect. The effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.

Standardized reporting of adverse events after microvascular decompression of cranial nerves; a population-based single-institution consecutive series

OBJECTIVE

To investigate frequencies of adverse events occurring within 30 days after microvascular decompression (MVD) surgery using a standardized report form of adverse events.

METHODS

We conducted a retrospective review of 98 adult patients (≥16 years) treated with MVD between 1 January 1994 and 1 June 2013. Adverse events occurring within 30 days were classified according to the Landriel Ibanez classification for neurosurgical complications: grade I represents any non-life threatening complication treated without invasive procedures; grade II is complications requiring invasive management; grade III is life-threatening adverse events requiring treatment in an intensive care unit (ICU); grade IV is death as a result of complications. We sought to compare our results with reports from the literature.

RESULTS

Patients' median age was 61 years (range 26-83), and 64 (65 %) were females. Indications for MVD were trigeminal neuralgia (n = 77, 79 %), glossopharyngeal neuralgia (n = 4, 4 %), hemifacial spasm (n = 16, 16 %) and combined trigeminal neuralgia and hemifacial spasm (n = 1, 1 %). The overall 30-day complication rate was 20 %, with 14 % grade I complications, 5 % grade II complications and 1 % grade III complications. The comparison with the literature was hampered by the diverse and unsystematic way of reporting complications.

CONCLUSION

We provide a standardized report of postoperative complications in a consecutive patient series undergoing MVD. Due to the heterogeneous and non-standardized reporting of complications in the literature, it is difficult to know if our 20 % complication rate is low or high. Standardized reporting is a necessity for meaningful and more valid comparisons across studies. The safety of MVD, a fairly standardized neurosurgical procedure, is well suited for comparisons across centers provided that complications are reported in a standardized manner.

Endoscopic management of cerebrospinal fluid rhinorrhea

Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.

Fully Endoscopic Retrosigmoid Vestibular Nerve Section for Refractory Meniere Disease

OBJECTIVE

This study aims to report our results and technical details of fully endoscopic retrosigmoid vestibular nerve section.

DESIGN

A prospective observational study was conducted.

SETTING

A single academic, tertiary institution involving neurosurgery and neurotology.

PARTICIPANTS

Previously diagnosed patients with Meniere disease, refractory to medical therapy, who underwent fully endoscopic vestibular nerve section.

MAIN OUTCOME MEASURES

Postoperative improvement in vertiginous symptoms as well as hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons score and the Gardener and Robertson-Modified Hearing Classification. Facial nerve preservation based on the House-Brackman (HB) score.

RESULTS

Symptoms improved or resolved in 38 of 41 (92.2%) patients with only 1 of 41 (2.4%) reporting worsening symptoms. All 41 patients (100%) had a postoperative HB score of 1/6, demonstrating full facial nerve preservation. Hearing was stable or improved in 34 of 41 (82.9%) patients. Three complications took place for a rate of 7.3%, one cerebrospinal fluid leak, and two wound infections.

CONCLUSION

The fully endoscopic approach to vestibular nerve sections is a safe and effective technique for the treatment of medically refractory Meniere disease. This technique also utilizes smaller incisions, minimal cranial openings, and no cerebellar retraction with improved visualization of the cerebellopontine angle neurovascular structures.

Role of endoscopic third ventriculostomy in tuberculous meningitis with hydrocephalus

Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM). It can be purely obstructive, purely communicating, or due to combinations of obstruction in addition to defective absorption of cerebrospinal fluid (CSF). Endoscopic third ventriculostomy (ETV) as an alternative to shunt procedures is an established treatment for obstructive hydrocephalus in TBM. ETV in TBM hydrocephalus can be technically very difficult, especially in acute stage of disease due to inflamed, thick, and opaque third ventricle floor. Water jet dissection can be helpful in thick and opaque ventricular floor patients, while simple blunt perforation is possible in thin and transparent floor. Lumbar peritoneal shunt is a better option for communicating hydrocephalus as compared to VP shunt or ETV. Intraoperative Doppler or neuronavigation can help in proper planning of the perforation to prevent neurovascular complications. Choroid plexus coagulation with ETV can improve success rate in infants. Results of ETV are better in good grade patients. Poor results are observed in cisternal exudates, thick and opaque third ventricle floor, acute phase, malnourished patients as compared to patients without cisternal exudates, thin and transparent third ventricle floor, chronic phase, well-nourished patients. Some of the patients, especially in poor grade, can show delayed recovery. Failure to improve after ETV can be due to blocked stoma, complex hydrocephalus, or vascular compromise. Repeated lumbar puncture can help faster normalization of the raised intracranial pressure after ETV in patients with temporary defect in CSF absorption, whereas lumbar peritoneal shunt is required in permanent defect. Repeat ETV is recommended if the stoma is blocked. ETV should be considered as treatment of choice in chronic phase of the disease in obstructive hydrocephalus.

Fully endoscopic microvascular decompression for trigeminal neuralgia: technique review and early outcomes

OBJECT

Fully endoscopicmicrovascular decompression (E-MVD) of the trigeminal nerve was initially described more than 1 decade ago, but has not yet gained wide acceptance. The authors present the experience of their first 47 consecutive E-MVDs for trigeminal neuralgia (TN).

METHODS

All surgeries were performed by a single surgeon (J.Y.K.L.) at the Pennsylvania Hospital at the University of Pennsylvania. Patients prospectively completed pain scales before and after surgery by using the Brief Pain Inventory-Facial outcomes tool. All patients were called on the telephone, and the same outcome tool was administered without reference to their preoperative pain status.

RESULTS

Forty-seven patients (17 men) were identified and enrolled. Forty (85%) had Burchiel Type 1 TN. Vascular compression was observed at surgery in 42 patients (89%). No surgery was aborted or converted to microscope. One patient suffered permanent hearing loss, for a permanent neurological morbidity rate of 2%. Overall improvement in pain outcomes was excellent, with a median maximum pain intensity preoperatively of 10 and postoperatively of 0 (p< 0.0001). The mean interference with global function scores were 6.2 preoperatively and reduced to 1.0 at last follow-up (p < 0.0001). The mean interference with facial function was 7.3 preoperatively and reduced to 1.2 at last follow-up (p < 0.0001). The mean follow-up period after surgery was 15 ± 8 months.

CONCLUSIONS

In experienced hands, E-MVD offers superb visualization and illumination and is both safe and effective, at least in the short term. Further longer-term study is needed to compare E-MVD to traditional microscopic MVD.

Endoscopic Resection of Vestibular Schwannomas

Objective To report our results and the technical details of fully endoscopic resection of vestibular schwannomas. Design Prospective observational study. Setting A single academic institution involving neurosurgery and neurotology. Participants Twelve consecutive patients who underwent fully endoscopic resection of a vestibular schwannoma. Main Outcome Measures Hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons (AAO-HNS) score as well as the Gardener and Robertson Modified Hearing Classification (GR). Facial nerve preservation based on the House-Brackmann (HB) score. Results All patients successfully underwent gross total resection. Facial nerve preservation rate was 92% with 11 of 12 patients retaining an HB score of 1/6 postoperatively. Hearing preservation rate was 67% with 8 of 12 patients maintaining a stable AAO-HNS grade and GR score at follow-up. Mean tumor size was 1.5 cm (range: 1-2 cm). No patients experienced postoperative cerebrospinal fluid leak, infection, or cranial nerve palsy for a complication rate of 0%. Mean operative time was 261.6 minutes with an estimated blood loss of 56.3 mL and average length of hospital stay of 3.6 days. Conclusion A purely endoscopic approach is a safe and effective option for hearing preservation surgery for vestibular schwannomas in appropriately selected patients.

Endoscopic vascular decompression for the treatment of trigeminal neuralgia: clinical outcomes and technical note

OBJECTIVE

This study sought to describe the operative technique and clinical outcomes in a series of 57 patients with trigeminal neuralgia treated with endoscopic vascular decompression (EVD) alone without the use of microscopy at any point.

METHODS

A prospective observational study was performed on 57 consecutive patients treated with EVD alone for trigeminal neuralgia from October 2005 to October 2010. Patient outcomes were evaluated with respect to pain abatement, complication rate, length of hospital stay, and overall operative time. Pain outcome was graded using the Barrow Neurological Institute pain intensity score (BNI), with BNI 1 considered an excellent result and BNI 2 or 3 considered a good result. Follow-up ranged from 12 to 72 months, with a mean of 32 months. In addition to reporting these cases, our operative technique for EVD is described in detail.

RESULTS

All 57 patients reported severe preoperative pain (BNI 5); 100% of patients achieved immediate postoperative pain control or complete pain relief (BNI 1 to 3), with 82% obtaining an excellent result of BNI 1, and 18% of patients reported good results of BNI 2 or 3. At follow-up, 56 of 57 patients (98%) reported complete relief or well controlled pain (BNI 1 to 3), with 75% obtaining an excellent result of BNI 1; 23% of patients obtained a good result of BNI 2 or 3. The complication rate was 4%, with no mortality. Mean length of hospital stay was 1.6 days, with a range of 1 to 5 days; mean operative time was 133 minutes.

CONCLUSIONS

EVD is a safe and highly effective alternative to the more traditional open microvascular decompression or the more recently developed endoscopically assisted microvascular decompression.

Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.