Predictors of Postoperative Diabetes Insipidus Following Endoscopic Resection of Pituitary Adenomas

Exploring factors behind Arginine-Vasopressine deficiency in endoscopic endonasal surgery for PitNET: a single-center analysis of 349 patients

Arginine-Vasopressine deficiency (AVP-D), formerly known as Central Diabetes Insipidus, is a well-known complication in surgery for sellar/parasellar masses. Although less frequent in endoscopic series than transcranial and microscopic transsphenoidal ones, AVP-D has been variably related to different factors. Focusing the work on pituitary Neuroendocrine Tumors (PitNET), all patients who were treated endoscopically at a single centre were retrospectively reviewed to analyze the occurrence of this complication. Patient's characteristics, radiological information, and operative data were collected for patients who underwent surgery for PitNET at the same Institution by a single surgeon in the period 2016-2022. AVP-D was diagnosed in the presence of new-onset hypotonic polyuria with or without hypernatremia and was defined persistent if required a treatment with desmopressine/DDAVP for more than 6 months. Out of 349 patients (mean age at surgery 57.5 years old) 44 (12.6%) developed AVP-D (25 transient and 19 permanent). Younger age, the presence of an intraoperative CSF leak, the maximum diameter of the lesion, its suprasellar extension (considering the presence of a visual deficit), consistency of the lesion (distinguishing 4 classes, soft, soft-fibrous, fibrous and fibrous-firm), the extent of resection and the functioning status showed some relationship at univariate analysis (p < 0.05) with this complication. Larger diameter and longer operative time were seen more frequently in permanent AVP-D. A more solid intraoperative consistency with the presence of adherences (class 4 vs. class 1, OR 11.14, 95%CI 1.20-103.4) and the appearance of an intraoperative CSF-leak (OR 8.27, 95%CI 3.92-17.47) maintained a statistical significance in the multivariate logistic regression, with an older age being a protective factor in developing this deficiency (OR 0.96, 95%CI 0.95-0.99). The recognition of factors that can predict the onset of AVP-D with a certain degree of accuracy enables the entire staff to pay greater attention to the patient at risk in the postoperative period, thus preventing AVP-D complications.

Analysis of factors associated with polyuria in spinal surgery: a retrospective study

BACKGROUND

Intraoperative urine output monitoring is an important indicator to judge patient volume, and perioperative polyuria can lead to a variety of complications, which seriously affect the quality of prognosis of patients. Previous studies have found that intraoperative polyuria in some patients may be associated with the use of anesthetic drugs, especially in spinal surgery patients, where cases of polyuria have been reported more commonly. Therefore, this retrospective study focused on the factors influencing polyuria during spinal surgery.

METHODS

Data from spine surgery patients in the Madison system of Tongji Hospital from September 2018 to December 2021 were collected. The age, sex, BMI, surgical information, preoperative and postoperative test results, LOS, and postoperative adverse reactions were extracted. The relevant data during the operation were recorded through the Madison system at the same time, including the time statistics of various types of surgery, the amount of liquid in and out of the operation, the use of anesthetic drugs, the use of vasoactive medications, and the results of blood gas analysis. The primary outcome was to analyze the factors influencing intraoperative polyuria. Secondary outcomes were analyzed, among adverse effects of intraoperative polyuria, etc. RESULTS: Among the 903 included patient data, we concluded that the factors influencing intraoperative polyuria were female (OR, 1.933, 95% CI, 1.457-2.565), dexmedetomidine (OR, 1.876, 95% CI, 1.338-2.631), dopamine (OR, 1.413, 95% CI, 1.406-1.910). At the same time, different surgical sites also affected the symptoms of polyuria (p < 0.001). Intraoperative polyuria symptoms led to an increase in the incidence of infection (p < 0.05) and secondary surgery (p < 0.05). The length of hospital stay was also increased (p < 0.05) compared with the normal urine output group. There was no significant difference in the time of operation and preoperative and postoperative examination information(p > 0.05).

CONCLUSIONS

Females, dexmedetomidine, dopamine may be risk factors for intraoperative polyuria. Intraoperative polyuria will lead to various postoperative adverse reactions, increasing the proportion of postoperative infection and secondary surgery.

Intraoperative Diagnosis and Management of Arginine Vasopressin Disorder During Pituitary Tumor Resection via Transsphenoidal Endoscopic Navigation

Arginine vasopressin (AVP) disorders (previously called diabetes insipidus) lead to excessive urination due to reduced antidiuretic hormone (ADH) secretion or kidney resistance to ADH. This results in decreased water reabsorption, causing dehydration and electrolyte imbalances. Diagnosing these disorders during general anesthesia is challenging, but close monitoring of electrolytes and urine output, especially during high-risk surgeries such as intracranial procedures, is crucial. A 64-year-old woman with a history of asthma presented with severe bifrontal headaches and left-eye medial gaze palsy. Imaging showed a large sellar mass extending into the sphenoid sinus, requiring a transsphenoidal resection. An hour and 30 minutes into surgery, the patient developed acute polyuria (1 L urine), hyperosmolality (Na: 149 mmol/L), and colorless urine with low specific gravity (1.003), indicating an arginine vasopressin disorder. Desmopressin (DDAVP) was administered, improving urine specific gravity to 1.013, and a D5W infusion corrected a 2.5 L fluid deficit. Severe hypokalemia (K: 2.6 mmol/L) and hyperglycemia (glucose: 230 mg/dL) were also treated, with electrolyte and glucose levels stabilizing postoperatively. On postoperative day (POD) 2, the patient experienced polyuria up to 23 L and excessive thirst, requiring additional desmopressin on POD 3. She was discharged on POD 9. Arginine vasopressin disorders, especially vasopressin deficiency (central diabetes insipidus), commonly result from neurohypophyseal damage during cranial surgery. Prompt diagnosis and treatment with desmopressin and fluids can effectively manage fluid and electrolyte imbalances, preventing severe complications such as hypernatremia and neurological deficits. This case highlights the importance of intraoperative urine and laboratory monitoring to ensure timely recognition and management.

Urinary oxytocin secretion after pituitary surgery, early arginine vasopressin deficiency and syndrome of inappropriate antidiuresis

PURPOSE

Transient arginine vasopressin deficiency (AVP-D), previously called diabetes insipidus, is a well-known complication of transsphenoidal pituitary surgery (TPS) with no definite predictive biomarker to date making it difficult to anticipate. While oxytocin (OXT) was previously suggested as a possible biomarker to predict syndrome of inappropriate diuresis (SIAD)-related hyponatraemia after TPS, its secretion in patients presenting with AVP-D remains poorly understood. We therefore hypothesized that OXT might present a different secretion in the case of AVP-D which would support its potential as an early biomarker of AVP-D. Moreover, we hypothesized that abnormal secretion of OXT might occur later on, notably with SIAD.

METHODS

We measured the urinary output of OXT in 67 consecutive patients subjected to TPS and compared the values of oxytocin between time-points and OXT ratio between groups. The primary endpoint of our study was to identify a difference in urinary OXT excretion in patients suffering from AVP-D compared to patients remaining normonatraemic. As a secondary endpoint, we compared the evolution of OXT secretion after the diagnosis of AVP-D in both groups, comparing the patients that later developed SIAD with the ones that did not.

RESULTS

Patients developing AVP-D showed a delay in the increase of OXT secretion after TPS as shown by a significantly lower ratio of OXT between the first postoperative day and the day of surgery (0.88 VS 1.68, p = 0.0162, IC:0.2979-0.2642) but a significantly higher ratio of OXT between the fourth and the first postoperative days (1.17 VS 0.53, p = 0.0006, IC:-2.109-0.6092). Moreover, normonatraemic patients that did not show normalization of OXT levels at day 4 after surgery tended to develop SIAD later on.

CONCLUSION

Taken together, these results show for the first time that OXT release might help predict AVP-D after TPS and differentiate it from other pathologies of water-sodium balance.

Short-term urinary catheter usage in endoscopic skull base surgery and impact on urinary tract infection and reconstructive outcomes

Objectives

Hospital-acquired catheter-associated urinary tract infections (UTIs) have been regarded as preventable adverse events, yet their risk in endoscopic skull base surgery (ESBS) has not been well described despite common use. We determine the incidence of UTI following ESBS and identify contributing clinical factors.

Methods

Retrospective review was conducted for a cohort of 229 consecutive adult patients who underwent endoscopic endonasal surgery for treatment of any skull base pathology between July 2018 and June 2022 at a tertiary academic skull base surgery program. Postoperative UTI comprised the primary outcome. Independent variables included patient demographics, use and length of urinary catheterization, and pre-existing genitourinary conditions.

Results

Nosocomial UTIs were identified in 1.3% (3/229) of patients, occurring on postoperative days 2, 9, and 14, respectively; all were catheter-associated. Overall, 86.0% (197/229) of patients received urinary catheters (mean duration 2.2 ± 1.8 days). Compared to those without, patients with UTI were older (70.0 ± 15.4 vs. 52.2 ± 16.8 years, p = 0.034), had lengthier stays (94.7 ± 126.8 vs. 5.9 ± 8.4 days, p < 0.001), and had prolonged catheterizations (9.3 ± 5.5 vs. 2.1 ± 1.5 days, p < 0.001). Preoperative genitourinary conditions were also associated with UTI development, namely, chronic urinary retention/obstruction (66.7% vs. 4.0%, p = 0.006), urinary incontinence (66.7% vs. 6.2%, p = 0.013), prostate disease (100.0% vs. 17.8%, p = 0.035), and renal dysfunction (100.0% vs. 9.7%, p = 0.001). Among intraoperative cerebrospinal fluid leak patients, postoperative CSF leak incidence was not associated with catheter use versus nonuse (3.3% vs. 12.5%, p = 0.276).

Conclusion

Although UTIs are uncommon in ESBS patients, advanced age, length of stay, duration of indwelling urinary catheterization, and comorbid genitourinary conditions may elevate risk.

Cost outcomes of pituitary adenoma resection: The use of a hybrid microscopic/endoscopic surgery

Background

The pathogenesis, surgical techniques, and outcomes of pituitary adenomas (PAs) remain variable. We compared our surgical techniques and perioperative/long-term PA outcomes to highlight the hybrid microscopic/endoscopic technique used to optimize efficiency, cost savings, and outcomes in PA surgery.

Methods

Consecutive PA cases performed from January 2017 through February 2020 were evaluated retrospectively. A cost analysis by surgical approach was performed combining this primarily microscopic series, with endoscopic visual assist, and a separate cohort of consecutive intra-institutional endoscopic-only PA resections.

Results

Among 160 patients included in the main cohort analysis (mean age 51.5 ± 16.2; 89 females [55.6%]), a microscope was used in 81.9% of cases, with endoscopic assistance (hybrid) or the endoscope alone used in the remaining cases. Surgical complications occurred in 5 cases (3.1%): postoperative diabetes insipidus in 3 (1.9%), electrolyte imbalances requiring additional drug treatment in 3 (1.9%), and syndrome of inappropriate anti-diuretic hormone release in 2 (1.2%). Thirty-three additional patients were included in the cost analysis (193 total). Patients treated with a microscopic-only approach had the lowest operating time (mean normalized operating room costs 1.00 [95% confidence interval (CI) 0.95, 1.04], P < 0.001; mean normalized total direct costs 5.00 [95%CI 4.69, 5.31], P = 0.008), with hybrid and endoscopic-only approaches having higher comparable operating times and costs.

Conclusion

PA surgery using a primarily microscopic approach (with endoscopic assistance for complex cases) remains a safe, efficient, and cost-effective strategy and results in shorter anesthesia time to reduce patient complications while maintaining excellent endocrinologic outcomes.

Keywords

Endoscope, Hybrid approach, Microscope, Pituitary adenoma, Transnasal surgery, Transsphenoidal surgery.

Risk Factors for Development of Diabetes Insipidus and Syndrome of Inappropriate Antidiuretic Hormone Secretion after Transsphenoidal Resection of Pituitary Adenoma

Background  We aimed to determine the incidence and risk factors for development of diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) after transsphenoidal hypophysectomy (TSH) for resection of a pituitary adenoma. Methods  This was a retrospective study of 403 adult patients undergoing TSH for pituitary adenoma. Clinical variables, tumor characteristics, and operative factors were collected. Incidences of DI and SIADH were determined, including timing in the perioperative period. Independent predictors of developing DI and SIADH were identified using multivariable logistic regression. Results  Following TSH, 21.3% of patients developed DI at a mean 2.6 days and 7.4% developed SIADH at a mean 4.7 days. DI was negatively associated with older age (odds ratio [OR] = 0.98, 95% confidence interval [CI]: 0.96-0.99, p  = 0.029). DI was positively associated with female sex (OR = 2.26, 95% CI: 1.24-4.11, p  = 0.008), increase in anteroposterior tumor size (OR = 1.54, 95% CI: 1.11-2.13, p  = 0.010), intraoperative cerebrospinal fluid (CSF) leak (OR = 2.29, 95% CI: 1.25-4.19, p  = 0.008), and every 100 mL of estimated blood loss (EBL) (OR = 1.18, 95% CI: 1.01-1.39, p  = 0.046). Development of SIADH was positively associated with intraoperative CSF leak (OR = 3.56, 95% CI: 1.24-10.21, p  = 0.018) on multivariate analysis. Conclusion  DI and SIADH occur in the minority of patients undergoing TSH, but vigilance for their development must be maintained for days after the surgery. Development of DI after TSH is multifactorial, having possible patient-specific risk factors and risk related to the complexity of surgical dissection, reflected by tumor size, intraoperative CSF leak, and EBL. Development of SIADH could be associated with intraoperative CSF leak occurrence.

Factors Associated With 30-Day Readmissions After Transsphenoidal Pituitary Surgery

PURPOSE

Determine the association between clinical and demographic factors and 30-day readmission risk after pituitary surgery.

METHODS

Patients undergoing pituitary surgery between January 2018 and December 2022 were retrospectively reviewed. Cases were extracted from a converged electronic health record that included surgeries performed at the Midwest, Southeast, and Southwest campuses of the same healthcare Enterprise. Variables were compared between patients with 30-day readmission following discharge after pituitary surgery (N = 83) and a randomly sampled patient cohort with pituitary surgery but no readmission within 30 days (N = 174).

RESULTS

In a multivariable regression model looking at the relationship between patient characteristics and readmission risk, every increase in the Medicare Severity Diagnosis Related Group score resulted in a nearly 2.3-fold increase in the risk of readmission (OR = 2.335, 95% CI 1.050, 5.562, P = .045). The presence of arginine vasopressin deficiency increased the odds of readmission by more than 2-fold (OR = 2.784, 95% CI 1.118, 7.124, P = .029). The Midwest site was observed to have a nearly 67% decrease in readmission risk compared to the Southwest site (OR = 0.334, 95% CI 0.134, 0.813, P = .016), with the Southeast site being comparable to the Southwest.

CONCLUSION

Our study identifies postoperative arginine vasopressin deficiency, greater co-morbidities, and geographic location as risk factors for 30-day readmission after pituitary surgery. Further investigation is required to determine how site-specific care processes can be adopted to lower readmission risk at other locations in the same healthcare enterprise.

Protective Strategies for Pituitary Function During Endoscopic Transnasal Pituitary Adenoma Surgery: A Single-center Experience

OBJECTIVE

This study investigated the impact of endoscopic transnasal pituitary adenoidectomy on function and discussed the factors that contribute to postoperative pituitary function. To provide a foundation for protecting pituitary function and improving the curative effect of pituitary adenoma neuroendoscope resection.

METHODS

From January 2019 to January 2022, in the Neurosurgery Pituitary Tumor Diagnosis and Treatment Research Center, the First Affiliated Hospital of Shenzhen University, the clinical data of 306 patients who underwent endoscopic transnasal pituitary adenoma surgery were analyzed retrospectively. The surgical treatment strategy was discussed and explored, while the factors related to pituitary function were examined based on tumor size and Knosp grade.

RESULTS

There were 40 cases (67.8%) of pituitary-thyroid axis, 18 cases (60%) of pituitary-adrenal axis, 25 cases (45.4%) of pituitary-gonad axis, 5 cases (62.5%) of pituitary-growth hormone axis, and 8 cases (72.7%) of diabetes insipidus with postoperative improves of hypopituitarism. Postoperative newly developed hypopituitarism occurred in 20 cases (8.1%) of pituitary-thyroid axis, 15 cases (5.4%) of pituitary-adrenal axis, 10 cases (4.0%) of pituitary-gonad axis, 5 cases (1.7%) of pituitary-growth hormone axis, and 8 cases (2.7%) of new diabetes insipidus. The incidence of pituitary-adrenal axis hypofunction in giant pituitary adenomas was significantly higher than that in microadenomas and macroadenomas (P<0.05). The incidence of hypopituitarism of Knosp grade 4 pituitary adenoma before operation was higher than that of other groups (P<0.05), but there was no significant difference in the incidence of new hypopituitarism after operation (P>0.05).

CONCLUSIONS

In endoscopic transnasal pituitary adenoma surgery, the incidence of hypothyroidism and adrenal gland dysfunction is higher than in other hormone axes, but the recovery rate is also higher, and the recovery rate of sex hormones is lower. The incidence of postoperative hypothyroidism increases dramatically with tumor size and tumor invasiveness.

Smartphone Applications for Remote Monitoring of Patients After Transsphenoidal Pituitary Surgery: A Narrative Review of Emerging Technologies

OBJECTIVE

Almost all postoperative assessments for pituitary patients are performed in clinical settings under the supervision of medical providers. With the emergence of telemedicine, however, there are opportunities to monitor these patients remotely. The potential for use of such technologies is inconsistently described in the brain tumor literature, especially for patients with pituitary adenomas.

METHODS

In this comprehensive narrative review, we present the literature for the use of mobile applications (apps) for monitoring of postoperative symptomatology that is specific to patients undergoing pituitary surgery. Our primary research question was: "Which smartphone apps exist in the literature to monitor parameters associated with common complications of pituitary surgery?" Specifically, we search for apps in the literature that facilitate the measurement of parameters associated with adrenal insufficiency, disorders of water imbalance, and visual changes-3 common complications of pituitary surgery.

RESULTS

Twenty-six apps were identified. Fourteen apps pertained to monitoring of visual changes, followed by 9 apps for monitoring water and electrolyte imbalances and 3 apps for monitoring adrenal dysfunction. Novel technologies that were integrated into these apps included digital image-based colorimetry, sonouroflowmetry, visual contrast sensitivity, and lateral flow immunoassays, among others.

CONCLUSIONS

Due to advancing capabilities of smartphone apps, the potential of telemedicine may extend beyond patient appointments. We show that by integrating novel advances in medical technologies from a variety of specialties, it is possible to develop smartphone-based protocols for remote monitoring of patients after pituitary surgery.

Predictive modeling of arginine vasopressin deficiency after transsphenoidal pituitary adenoma resection by using multiple machine learning algorithms

This study aimed to predict arginine vasopressin deficiency (AVP-D) following transsphenoidal pituitary adenoma surgery using machine learning algorithms. We reviewed 452 cases from December 2013 to December 2023, analyzing clinical and imaging data. Key predictors of AVP-D included sex, tumor height, preoperative and postoperative changes in sellar diaphragm height and pituitary stalk length, preoperative ACTH levels, changes in ACTH levels, and preoperative cortisol levels. Six machine learning algorithms were tested: logistic regression (LR), support vector classification (SVC), random forest (RF), decision tree (DT), k-nearest neighbors (KNN), and extreme gradient boosting (XGBoost). After cross-validation and parameter optimization, the random forest model demonstrated the highest performance, with an accuracy (ACC) of 0.882 and an AUC of 0.96. The decision tree model followed, achieving an accuracy of 0.843 and an AUC of 0.95. Other models showed lower performance: LR had an ACC of 0.522 and an AUC of 0.54; SVC had an ACC of 0.647 and an AUC of 0.67; KNN achieved an ACC of 0.64 and an AUC of 0.70; and XGBoost had an ACC of 0.794 and an AUC of 0.91. The study found that a shorter preoperative pituitary stalk length, significant intraoperative stretching, and lower preoperative ACTH and cortisol levels were associated with a higher likelihood of developing AVP-D post-surgery.

Hypopituitarism, Diabetes Insipidus, and Syndrome of Inappropriate Antidiuretic Hormone Secretion after Pituitary Macroadenoma Surgery with Indocyanine Green Dye

(1) Background: Pituitary adenomas are benign tumors comprising about 18% of all intracranial tumors, and they often require surgical intervention. Differentiating pituitary tissue from adenoma during surgery is crucial to minimize complications. We hypothesized that using ICG dye would reduce the hormonal complication rates. (2) Methods: A prospective randomized study (February 2019-October 2023) included 34 patients with non-functional macroadenomas of the pituitary gland randomly assigned to receive intraoperative ICG or be in the control group. All underwent endoscopic endonasal transsphenoidal surgery. Pituitary function was assessed preoperatively, immediately postoperatively, and 3-6 months postoperatively. Adenohypophysis function was evaluated with hormonal tests (Cosyntropin stimulation test, TSH, fT3, fT4, prolactin, IGF-1, FSH, LH, and testosterone in men) and neurohypophysis function with fluid balance, plasma and urine osmolality, and serum and urinary sodium. (3) Results: Of the 34 patients (23 men, 11 women; average age 60.9 years), 5.9% in the ICG group developed diabetes insipidus postoperatively, compared to 23.5% in the control group. Adenohypophysis function worsened in 52.9% of the ICG group and in 35.3% of the control group. (4) Conclusions: Our study did not confirm the benefits of using ICG in these surgeries. Further research with a larger sample is needed.

Clinical and radiographic characteristics of patients with non-functioning pituitary adenomas categorized according to their serum prolactin concentration: novel predictors of postoperative transient diabetes insipidus following surgery

PURPOSE

Non-functioning pituitary adenomas (NFPAs) are often associated with hyperprolactinemia, which is known as the "stalk effect". However, the relationships between hyperprolactinemia and the radiographic characteristics of the tumor that affects the pituitary stalk have not been well characterized. We aimed to identify the differences in the clinical and radiographic characteristics of patients with NFPA, with and without hyperprolactinemia.

METHODS

We enrolled 107 patients with NFPA and allocated them to hyperprolactinemia and non-hyperprolactinemia groups using two different cut-off values: (1) the upper limit of the normal reference range, adjusted for sex and menopausal status, and (2) the upper quartile across the cohort, and compared their clinical and radiographic characteristics. These analyses were conducted to clarify the relationship between the "stalk effect" and the postoperative change in antidiuretic hormone secretion.

RESULTS

The specific radiographic characteristics of the patients included the presence of a cystic or hemorrhagic tumor and the presence of pituitary stalk deviation, which were more frequent in the patients with hyperprolactinemia. Interestingly, the incidence of postoperative transient diabetes insipidus was statistically significantly higher in the hyperprolactinemia group (≥40 ng/mL) and in the group with radiologic evidence of stalk deviation, which were shown to be independent risk factors on multivariate analysis.

CONCLUSION

The presence of a "stalk effect" was associated with a higher risk of postoperative transient diabetes insipidus, reflecting perioperative pituitary stalk dysfunction following NFPA surgery, especially in patients with serum prolactin concentrations ≥40 ng/mL and radiologic evidence of stalk deviation.

Clinical and Surgical Outcomes of Endoscopic Endonasal Approach for Giant Pituitary Adenomas: Analysis of Predictive Factors

BACKGROUND

Giant pituitary adenomas (GPAs) are defined as tumors with ≥40 mm in any maximum diameter, and these tend to invade multiple intracranial compartments. Hence, treatment remains a surgical challenge.

OBJECTIVE

To describe the clinical and surgical outcomes of the endoscopic endonasal approach (EEA) for GPA in a pituitary referral center in Latin America and to analyze associated predictive factors.

METHODS

37 patients with histologically-confirmed GPA treated solely through the EEA between a 2-year period were included. Preoperative and postoperative clinical and neuroimaging findings; surgical morbidity and mortality; and binary logistic regression analysis to assess predictive factors were analyzed.

RESULTS

Preoperative visual impairment prevalence was 97.3%. Mean tumor volume was 32 cc and gross total resection rate was 40.5%. Favorable visual acuity and visual fields outcome rate was 75% and 82.9%, respectively. In the multivariate analysis, bilateral cavernous sinus invasion (P = 0.018) and postoperative cerebrospinal fluid (CSF) leak (P = 0.036) were associated with an unfavorable visual acuity outcome, while radiation therapy (P = 0.035) was for visual fields. Similarly, intraoperative CSF leak was a predictive factor for postoperative CSF leak (10.8%) (P = 0.042) and vascular injury (13.5%) (P = 0.048).

CONCLUSIONS

In this first Mexican clinical series, we demonstrated that the EEA is a safe and effective technique for GPA, although early diagnosis and prompt intervention may promote further visual function preservation without significant endocrine morbidity.

Importance of Intraoperative Factors in Postoperative Arginine Vasopressin Deficiency After Pituitary Adenoma Surgery

OBJECTIVE

Pituitary adenoma (PA) is the most frequent tumor in the sellar region. Arginine vasopressin deficiency (AVP-D), formerly known as central diabetes insipidus, is a common complication after pituitary surgeries. In this study, we reviewed patients with PAs after endoscopic transsphenoidal surgery, evaluated the incidence of postoperative AVP-D, and determined associated risk factors.

METHODS

We retrospectively studied 520 patients who underwent endoscopic transsphenoidal surgery for PAs and evaluated perioperative risk factors and their associations with postoperative AVP-D. Patients who developed AVP-D were categorized in 3 groups: (1) early AVP-D, (2) transient AVP-D, and (3) permanent AVP-D.

RESULTS

Of the 520 patients, 24.8% experienced early AVP-D, and 1.9% (n = 10) had transient AVP-D. Permanent AVP-D was observed in only 6 patients (1.1%). Gross total resection, hormonal remission, pituitary stalk manipulation, and intraoperative cerebrospinal fluid leak were significantly associated with a higher incidence of AVP-D (P = .027, P = .002, P < .001 and P < .001, respectively). All patients who developed permanent AVP-D had somatotroph adenomas. AVP-D was not found to be related with tumor size. The length of hospital stay was prolonged by AVP-D on average by 1.5 days (P = .018).

CONCLUSION

The reported incidence of AVP-D has a considerably wide range. A consistent definition and grading for AVP-D will increase consistency and comparability among studies. Nonetheless, most patients experience AVP-D on a temporary basis, and only a few require long-term treatment. Cerebrospinal fluid leak, gross total resection, and hormonal remission were identified as risk factors for postoperative AVP-D. We believe that the intraoperative risk factors play the main role in postoperative AVP-D. The course of surgery and operative findings help us plan selective postoperative patient monitoring and care.

Clinical study on the selection of endoscopes and microscopes for transsphenoidal surgery of non-aggressive pituitary macroadenoma and microadenoma and the influencing factors of hyposmia after endoscopic transsphenoidal surgery

Background and objective

Transsphenoidal surgery, including endoscopic and microscopic resection, is the first choice of treatment for pituitary tumors. With the widespread application of neuroendoscopy in recent decades, there has been a trend to replace microscopes. In clinical practice, we have found that in transsphenoidal surgery for non-invasive microadenomas and macroadenomas, microscopy can achieve a higher total resection rate, shorter operation time, lower incidence of postoperative complications, and faster recovery of olfaction. This study aimed to explore the selection of endoscopes and microscopes for non-aggressive transsphenoidal surgery for pituitary adenomas and the factors affecting olfactory recovery.

Methods

From August 2019 to October 2022, 93 patients with non-aggressive microadenomas and macroadenomas via the transsphenoidal approach were selected from the First Affiliated Hospital of Harbin Medical University and treated with rich experience in pituitary tumor subspecialty microscopy and endoscopic surgery. Different surgical methods were used to divide the patients into microscopic (n = 35) and endoscopic (n = 58) groups. The total tumor removal rate, intraoperative blood loss, operation time and cost, postoperative hospital stay, recovery of visual function, postoperative changes in hormone levels, complication rate, and recovery from complications 3 months after the operation were compared between the two groups.

Results

There were no significant differences in the tumor removal rate, postoperative visual acuity, and visual field recovery between the two groups (p > 0.05). There was a significant difference in the recovery rate of olfactory function between the two groups 3 months after the operation (p < 0.05), and there was no significant difference in the incidence of other complications (p > 0.05); Compared with the two groups, the microscope group had shorter operation time, longer postoperative hospital stay, less average operation cost and less blood loss, and the difference was statistically significant (p < 0.05). The position of the nasal septum mucosal flap incision was a risk factor for hyposmia 3 months after the operation.

Conclusion

Microsurgery and endoscopic surgery are suitable surgical treatments for nonaggressive microadenomas and macroadenomas. The total tumor removal and postoperative hormone remission rates of the two surgical methods were approximately the same. However, the microsurgery group had a shorter operation time, less intraoperative blood loss, faster olfactory function recovery, and a lower average operation cost. The position of the nasal septal mucosal flap incision was a risk factor for hyposmia at 3 months postoperatively. Hyposmia is less likely to occur when the superior edge of the nasal septal mucosal flap incision is not higher than the lower edge of the ipsilateral superior turbinate.

Risk Factors Related to Transient Diabetes Insipidus Development Following Transsphenoidal Pituitary Adenoma Resection: A Multicentric Study

OBJECTIVE

To analyze and find risk factors associated with developing transient diabetes insipidus (DI) using a multicenter case series after trans-sphenoidal surgery.

METHODS

Medical records of patients who underwent trans-sphenoidal surgery for pituitary adenoma resection between 2010 and 2021 at 3 different neurosurgical centers by 4 experienced neurosurgeons were retrospectively analyzed. The patients were divided into 2 groups (DI group or control group). Logistic regression analysis was conducted to identify risk factors associated with postoperative DI. Univariate logistic regression was performed to identify variables of interest. Covariates with a P value <0.05 were incorporated into multivariate logistic regression models to identify independently associated risk factors for DI. All statistical tests were conducted using RStudio.

RESULTS

A total of 344 patients were included; 68% were women, the mean age was 46.5 years, and nonfunctioning adenomas were the most frequent (171, 49.7%). The mean tumor size was 20.3 mm. Covariates associated with postoperative DI were age, female gender, and gross total resection. The multivariable model showed that age (odds ratio [OR] 0.97, CI 0.95-0.99, P = 0.017) and female gender (OR 2.92, CI 1.50-6.03, P = 0.002) remained significant predictors of DI development. Gross total resection was no longer a significant predictor of DI in the multivariable model (OR 1.86, CI 0.99-3.71, P = 0.063), suggesting that this variable may be confounded by other factors.

CONCLUSIONS

The independent risk factors for the development of transient DI were female and young patients.

A Machine Learning-Based Prediction of Diabetes Insipidus in Patients Undergoing Endoscopic Transsphenoidal Surgery for Pituitary Adenoma

BACKGROUND

Diabetes insipidus (DI) is a common complication after endoscopic transsphenoidal surgery (TSS) for pituitary adenoma (PA), which affects the quality of life in patients. Therefore, there is a need to develop prediction models of postoperative DI specifically for patients who undergo endoscopic TSS. This study establishes and validates prediction models of DI after endoscopic TSS for patients with PA using machine learning algorithms.

METHODS

We retrospectively collected information about patients with PA who underwent endoscopic TSS in otorhinolaryngology and neurosurgery departments between January 2018 and December 2020. The patients were randomly split into a training set (70%) and a test set (30%). The 4 machine learning algorithms (logistic regression, random forest, support vector machine, and decision tree) were used to establish the prediction models. Area under the receiver operating characteristic curves were calculated to compare the performance of the models.

RESULTS

A total of 232 patients were included, and 78 patients (33.6%) developed transient DI after surgery. Data were randomly divided into a training set (n = 162) and a test set (n = 70) for development and validation of the model, respectively. The area under the receiver operating characteristic curve was highest in the random forest model (0.815) and lowest in the logistic regression model (0.601). Invasion of pituitary stalk was the most important feature for model performance, closely followed by macroadenomas, size classification of PA, tumor texture, and Hardy-Wilson suprasellar grade.

CONCLUSIONS

Machine learning algorithms identify preoperative features of importance and reliably predict DI after endoscopic TSS for patients with PA. Such a prediction model may enable clinicians to develop individualized treatment strategy and follow-up management.

Diabetes insipidus related to sedation in the intensive care unit: A review of the literature

PURPOSE

To identify cases of diabetes insipidus (DI) related to sedation in the ICU to determine which medications pose the greatest risk and understand patterns of presentation.

MATERIALS AND METHODS

We searched PubMed, Embase, Scopus, Google Scholar, and Web of Science. Search terms included "polyuria," "diabetes insipidus," "hypnotics and sedatives," "sedation," as well as individual medications. Case reports or series involving DI or polyuria related to sedation in the ICU were identified.

RESULTS

We identified 21 cases of diabetes insipidus or polyuria in the ICU attributed to a sedative. Dexmedetomidine was implicated in 42.9% of cases, followed by sevoflurane (33.3%) and ketamine (23.8%). Sevoflurane was implicated in all 7 cases in which it was used (100%; 95% CI 59.0%, 100.0%), dexmedetomidine in 9 of 11 cases (81.8%; 95% CI 48.2, 97.7), and ketamine in 5 of 9 cases (55.6%; 95% CI 21.2%, 86.3%).

CONCLUSIONS

Awareness of the potential for sedatives to cause DI may lead to greater identification with swifter medication discontinuation and subsequent resolution of DI.

Functioning Endocrine Outcome after Endoscopic Endonasal Transsellar Approach for Pituitary Neuroendocrine Tumors

BACKGROUND

The endoscopic endonasal approach (EEA) is a well-established technique for the treatment of pituitary neuroendocrine tumor Preservation of normal gland tissue is crucial to retain effective neuroendocrine pituitary function. The aim of this paper is to analyze pituitary endocrine secretion after EEA for pituitary neuroendocrine tumor to identify potential predictors of functioning gland recovery.

METHODS

Patients who underwent an exclusive EEA for pituitary neuroendocrine tumors between October 2014 and November 2019 were reviewed. Patients were divided into groups according to postoperative pituitary function (Group 1, unchanged; group 2, recovering; group 3, worsening).

RESULTS

Among the 45 patients enrolled, 15 presented a silent tumor and showed no hormonal impairment, and 30 patients presented pituitary dysfunction. A total of 19 patients (42.2%) were included in group 1, 12 (26.7%) patients showed pituitary function recovery after surgery (group 2), and 14 patients (31.1%) exhibited the onset of new pituitary deficiency postoperatively (group 3). Younger patients and those with functioning tumor were more likely to have complete pituitary hormonal recovery (p = 0.0297 and p = 0.007, respectively). No predictors of functional gland worsening were identified.

CONCLUSION

EEA for pituitary neuroendocrine tumor is a reliable and safe technique regarding postoperative hormonal function. Preserving pituitary function after tumor resection should be a primary goal in a minimally invasive approach.

Patient perspectives on indwelling urinary catheters and fluid balances after transsphenoidal pituitary surgery: a qualitative study

OBJECTIVES

To explore the perceptions and experiences of patients who underwent transsphenoidal pituitary gland and (para)sellar tumour surgery regarding indwelling urinary catheters (IDUCs) and the postoperative fluid balance.

DESIGN

Qualitative study using semistructured interviews based on the attitudes, social influence and self-efficacy model and expert knowledge.

PARTICIPANTS

Twelve patients who underwent transsphenoidal pituitary gland tumour surgery and received an IDUC during or after surgery.

SETTING

One patient was interviewed in the endocrinology outpatient clinic and 11 patients were interviewed on the neurosurgery ward.

RESULTS

Five major themes emerged: (1) conflicting information and preoperative expectations, (2) IDUCs perceived as patient-friendly during bedrest, particularly for women, (3) little room for patients' opinions, (4) physical and emotional limitations and (5) fluid balance causes confusion. Information regarding IDUC placement and fluid balance given to patients both preoperatively and postoperatively did not meet their expectations, which led to confusion and uncertainty. The IDUC was perceived as preferable if bedrest was mandatory, preferred particularly by women. Patient could not mobilise freely due to the IDUC and felt ashamed, judged by others and dependent on nurses.

CONCLUSIONS

This study provides insight into the challenges patients experience in relation to the IDUC and fluid balance. Perceptions on the necessity of an IDUC varied among patients and were influenced by both physical and emotional impediments. A clear, frequent and daily communication between healthcare professionals and patients to evaluate IDUC and fluid balance use is necessary to increase patient satisfaction.

Pituitary Stalk Stretch Predicts Postoperative Diabetes Insipidus After Pituitary Macroadenoma Transsphenoidal Resection

BACKGROUND

Manipulation of the pituitary stalk, posterior pituitary gland, and hypothalamus during transsphenoidal pituitary adenoma resection can cause disruption of water electrolyte regulation leading to diabetes insipidus (DI).

OBJECTIVE

To determine whether pituitary stalk stretch is an independent risk factor for postoperative DI after pituitary adenoma resection.

METHODS

A retrospective review was performed of patients undergoing endoscopic endonasal resection of pituitary macroadenoma between July 2010 and December 2016 by a single neurosurgeon. We analyzed preoperative and postoperative imaging metrics to assess predictors for postoperative DI.

RESULTS

Of the 234 patients undergoing resection, 41 (17.5%) developed postoperative DI. DI was permanent in 10 (4.3%) and transient in 31 (13.2%). The pituitary stalk stretch, measured as the change in stalk length from preoperative to postoperative imaging, was greater in the DI compared with the non-DI group (10.1 mm vs 5.9 mm, P < .0001). The pituitary stalk stretch was associated with DI with significant difference in mean pituitary stalk stretch between non-DI group vs DI group (5.9 mm vs 10.1 mm, P < .0001). Multivariate analysis revealed that pituitary stalk stretch >10 mm was a significant independent predictor of postoperative DI [odds ratios = 2.56 (1.10-5.96), P = .029]. When stratified into transient and permanent DI, multivariable analysis showed that pituitary stalk stretch >10 mm was a significant independent predictor of transient DI [odds ratios = 2.71 (1.0-7.1), P = .046] but not permanent DI.

CONCLUSION

Postoperative pituitary stalk stretch after transsphenoidal pituitary adenoma surgery is an important factor for postoperative DI. We propose a reconstruction strategy to mitigate stalk stretch.

Effect of pituitary adenoma consistency on surgical outcomes in patients undergoing endonasal endoscopic transsphenoidal surgery

BACKGROUND

Most pituitary adenomas (PAs) are considered to have a soft tumor consistency. However, there is a non-negligible percentage (5-13%) of tumors presenting or exhibiting a fibrous consistency that would entail a more difficult and complicated surgical excision with higher surgical morbidity and mortality rates.

PURPOSE

To analyze the clinical consequences of PA tumor consistency on the surgical outcomes in patients undergoing endonasal endoscopic transsphenoidal (EET) pituitary surgery.

METHODS

An ambispective study of patients with PAs operated on through an EET approach in two Spanish tertiary hospitals over the last 12 years. A total of 226 consecutive interventions were carried out in the Neurosurgery Departments of the Hospital Universitario Ramón y Cajal (HURC) and the Hospital Universitario Puerta del Sur by the same neurosurgeon. PAs were grouped into soft (n = 150) and fibrous (n = 76). All patients underwent hormonal and magnetic resonance imaging (MRI) studies before and after surgery. In addition, neurosurgical complications were recorded in each patient.

RESULTS

Fibrous adenomas were independently associated with lower resection rates compared to soft adenomas (fibrous gross total resection [GTR] rate 48.7% vs. 76.3%, p &lt; 0.001), even in those adenomas without invasion of the cavernous sinus (Knosp grades 0, I, and II). There were more intraoperative cerebrospinal fluid (CSF) leaks in patients with fibrous PAs. Moreover, fibrous PAs showed higher rates of postoperative hypopituitarism, permanent diabetes insipidus (DI) and postoperative treatments (hormonal treatment and radiotherapy). The excision of a fibrous PA required a longer surgical time (22.5 min more than soft PAs, p = 0.014), regardless of other factors.

CONCLUSION

The consistency of the PAs significantly conditions both the results of surgery (lower resections rates), complications (higher incidence of postoperative hypopituitarism, permanent DI), and the prognosis (higher incidence of postoperative treatments) of the patient undergoing EET.

Change in the pituitary stalk deviation angle after transsphenoidal surgery can predict the development of diabetes insipidus for pituitary adenomas

Purpose

We aimed to assess the factors influencing the development of diabetes insipidus after transsphenoidal surgery for pituitary adenomas.

Methods

A retrospective analysis was conducted on the clinical data of patients with pituitary adenomas who underwent transsphenoidal surgery. The predictors of postoperative diabetes insipidus were determined using statistical analysis.

Results

Of the 415 patients who underwent microscopic transsphenoidal surgery for pituitary adenomas, 196 experienced postoperative diabetes insipidus. The sinking depth of the diaphragma sellae and the difference between the preoperative and postoperative pituitary stalk deviation angles in the diabetes insipidus group were greater than those in the non-diabetes insipidus group. Logistic regression analysis showed that the risk of diabetes insipidus after transsphenoidal surgery was higher in patients with a larger difference in their pituitary stalk deviation angles (odds ratio = 2.407, 95% CI = 1.335-4.342; P = 0.004).

Conclusion

The difference in the pituitary stalk deviation angle could predict the onset of diabetes insipidus after transsphenoidal surgery for pituitary adenomas.

Disparities in Postoperative Endocrine Outcomes After Endoscopic-Assisted Transsphenoidal Pituitary Adenoma Resection

Objectives Socioeconomic factors can influence morbidity in patients with pituitary adenoma. This study aims to identify associations between socioeconomic factors and postoperative outcomes in patients with pituitary adenomas. Methods A retrospective medical chart review was conducted on adult patients who underwent resection of purely sellar nonfunctional and functional pituitary adenomas between May 1, 2014, and May 31, 2020, at the University of North Carolina Medical Center. The main outcome measures included the incidence of postoperative diabetes insipidus (PDI), postoperative hyponatremia (PHN), and postoperative hypopituitarism (PHP). Outcome measures were analyzed using univariate and multivariate analyses against preoperative tumor volume as well as socioeconomic and demographic factors (self-identified race/ethnicity, age, gender, address assessed by the Area Deprivation Index (ADI), and insurance status). Results On univariate analysis, patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods had an increased incidence of postoperative diabetes insipidus. Patients who experienced PDI were significantly younger on average in both univariate and multivariate analyses. When analyzed further, patients of Hispanic race/ethnicity were significantly younger and more likely to be uninsured compared to their respective racial/ethnic counterparts. No significant correlations were found for PHN or PHP. Conclusions Patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods were more likely to experience PDI. This finding, when combined with findings regarding age and insurance status, suggests complex disparities in medical care that are confirmed or corroborated by prior literature. These results may enhance clinicians' management of patients from disadvantaged socioeconomic backgrounds through increased awareness of disparities and the provision of resources for assistance.

Identifying risk factors for postoperative diabetes insipidus in more than 2500 patients undergoing transsphenoidal surgery: a single-institution experience

OBJECTIVE

Diabetes insipidus (DI) following transsphenoidal surgery can adversely impact quality of life and be difficult to manage. This study sought to characterize pre- and perioperative risk factors that may predispose patients to DI after pituitary surgery.

METHODS

A retrospective review of patients treated at a single institution from 2007 to 2019 was conducted. DI was defined as postoperative sodium > 145 mEq/L and urine output > 300 ml/hr and/or postoperative desmopressin (ddAVP) use. DI was further characterized as transient or permanent. Uni- and multivariate analyses were performed to determine variables associated with postoperative DI.

RESULTS

The authors identified 2529 patients who underwent transsphenoidal surgery at their institution. Overall, DI was observed in 270 (10.7%) of the 2529 patients, with 114 (4.5%) having permanent DI and 156 (6.2%) with transient symptoms. By pathology type, DI occurred in 31 (46.3%) of 67 craniopharyngiomas, 10 (14.3%) of 70 apoplexies, 46 (14.3%) of 322 Rathke's cleft cysts, 77 (7.7%) of 1004 nonfunctioning pituitary adenomas (NFPAs), and 62 (7.6%) of 811 functioning pituitary adenomas (FPAs). Final lesion pathology significantly affected DI rates (p < 0.001). Multivariate analysis across pathologies showed that younger age (odds ratio [OR] 0.97, p < 0.001), intraoperative CSF encounter (OR 2.74, p < 0.001), craniopharyngioma diagnosis (OR 8.22, p = 0.007), and postoperative hyponatremia (OR 1.50, p = 0.049) increased the risk of DI. Because surgery for each pathology created specific risk factors for DI, the analysis was then limited to the 1815 pituitary adenomas (PAs) in the series, comprising 1004 NFPAs and 811 FPAs. For PAs, younger age (PA: OR 0.97, p < 0.001; NFPA: OR 0.97, p < 0.001; FPA: OR 0.97, p = 0.028) and intraoperative CSF encounter (PA: OR 2.99, p < 0.001; NFPA: OR 2.93, p < 0.001; FPA: OR 3.06, p < 0.001) increased DI rates in multivariate analysis. Among all PAs, patients with DI experienced peak sodium levels later than those without DI (postoperative day 11 vs 2). Increasing tumor diameter increased the risk of DI in FPAs (OR 1.52, p = 0.008), but not in NFPAs (p = 0.564).

CONCLUSIONS

In more than 2500 patients treated at a single institution, intraoperative CSF encounter, craniopharyngioma diagnosis, and young age all increased the risk of postoperative DI. Patients with postoperative hyponatremia exhibited higher rates of DI, suggesting possible bi- or triphasic patterns to DI. Greater vigilance should be maintained in patients meeting these criteria following transsphenoidal surgery to ensure early recognition and treatment of DI.

Analysis of neuroendoscopy for the treatment of macroadenomas and giant pituitary adenomas

Objective

This study investigated the use and effectiveness of endoscopic transnasal, transsphenoidal surgery, a minimally invasive method for the treatment of macroadenomas and giant pituitary a denomas, in a medical setting. The surgical results of 429 patients who received neuroendoscopic treatment of macroadenomas or giant pituitary adenomas were evaluated, and the experiences and lessons learned from treatment complications were assessed.

Patients and methods

From January 2012 to December 2021, 429 patients with macroadenomas or giant pituitary adenomas, including 60 patients with giant adenomas (diameter ≥4 cm) and 369 patients with macroadenomas (diameter 1–4 cm), received a 3D head CT, a MRI with contrast enhancement, and an endocrinology examination prior to surgery. Preoperative clinical and radiological features, visual measurements, hormone levels, length of stay, length of surgery, postoperative stay, visual and hormone outcomes, resection range, complication and recurrence rates, and routine patient information were recorded. The patients were followed up for 6–72 months (median = 40 months).

Results

Of 429 patients with macroadenomas or giant pituitary adenomas who received neuroendoscopic treatment, 348 (81.12%) had gross-total resections (GTR), 53 (12.35%) had near-total resections (NTR), and 28 (6.53%) had subtotal resections. There were 138 cases of post-operative diabetes insipidus (32.17%), including 7 cases of permanent diabetes insipidus (1.63%), 16 cases of nasal hemorrhage (3.73%), 39 cases of intraoperative cerebrospinal fluid leakage (9.09%), 4 cases of intracranial infection (0.9%), 16 cases of hypophysis (3.7%), and 15 cases of anosmia (3.50%). The clinical symptoms and endocrinology indices of the patients improved after surgery, and all patients were discharged 5–18 days (8.36 ± 2.65) postop.

Conclusion

Neuroendoscopy is a safe operation with a short recovery period and hospital stay and is thus an effective method to treat macroadenomas and giant pituitary adenomas. Preoperative evaluation and prediction can help to accurately address possible intraoperative situations and improve GTR.

Complication Rates after Endoscopic Transsphenoidal Surgery for ACTH-Secreting Pituitary Adenomas: A Comparative Analysis with GH and Nonfunctioning Adenomas

Objectives Some complications have been more frequently reported after surgery for adrenocorticotropin hormone (ACTH)-secreting pituitary adenomas. We compared complication rates in patients with ACTH-secreting pituitary adenomas with those in patients with growth hormone secreting pituitary adenomas (growth hormone [GH] group) and nonfunctioning adenomas (nonfunctioning group).

Design A comparative three-group analysis was performed for all patients who had endoscopic transsphenoidal surgery for pituitary adenomas at our center between January 2011 and May 2019. Variables included demographics, preoperative clinical and radiological characteristics, and postoperative radiological and endocrinological outcomes. Complications were divided into four categories: endocrinological, neurosurgical, medical, and ENT (ear–nose–throat)-related complications. Univariate and multivariate statistical analysis were performed.

Results A total of 111 patients with pituitary adenomas and a mean age of 53.7 years were included (25 ACTH, 35 GH, and 51 nonfunctioning adenomas). Overall, 28 patients had microadenomas (25.2%) and 83 had macroadenomas (74.8%). Univariate statistical analysis for complications between groups showed no differences in neurosurgical and medical complications. Transient diabetes insipidus and postsurgical bacterial sinusitis were the only variables more frequently seen in the ACTH group (p = 0.01 and 0.04, respectively). Multivariate analysis for transient diabetes insipidus showed no differences between groups (p = 0.58).

Conclusion Complication rates were similar in all three adenoma groups, particularly concerning major infections, thrombotic events, postoperative cerebrospinal fluid (CSF) leak, and transient diabetes insipidus. Transient diabetes insipidus was related with adenoma size and intraoperative CSF leak. Despite postoperative bacterial sinusitis was statistically higher in the ACTH group, this data should be interpreted with caution given the low number of patients with this complication.

Change in cephalocaudal tumor cavity diameter after transsphenoidal surgery is a predictor of diabetes insipidus in pituitary adenoma

Objective

To assess the factors influencing the development of diabetes insipidus after transsphenoidal surgery for pituitary adenomas.

Methods

We retrospectively analyzed the clinical data of patients with pituitary adenoma who underwent transsphenoidal surgery. The pituitary gland was assessed using a 3.0 T magnetic resonance imaging, and the predictors of postoperative diabetes insipidus were determined through univariate and multivariate analyses.

Results

A total of 212 eligible patients with pituitary adenomas were included; 82 (38.7%) cases developed postoperative diabetes insipidus while 130 cases (61.3%) did not. Diabetes insipidus was transient in 80 (37.7%) patients and permanent in 2 (0.9%) patients. The results of logistic regression analyses showed that the change in cephalocaudal tumor cavity diameter after transsphenoidal surgery was associated with the occurrence of postoperative diabetes insipidus.

Conclusions

Change in cephalocaudal tumor cavity diameter after transsphenoidal surgery may play an important role in predicting diabetes insipidus onset in patients with a pituitary adenoma.

Predicting the Need for Desmopressin Treatment During Inpatient and After Discharge Following Endoscopic Sellar Surgery

Introduction

Postoperative diabetes insipidus (DI) is a common complication following endoscopic sellar surgery. However, the requirement of desmopressin treatment for patients with DI are heterogenous. Although the predictors of postoperative DI have been reported, whether these patients required desmopressin treatment remained uninvestigated. Predicting the need of desmopressin can benefit clinical decision making more directly than predicting the occurence of postoperative DI. This study aimed to identify variables that predict the need for desmopressin treatment following sellar surgery.

Methods

Patients undergoing endoscopic sellar surgery between 2016 and 2019 were retrospectively reviewed. Twenty-three variables, characterized as potential predictors for requiring desmopressin treatment, were analyzed. To assess the capability to generalize the identified predictors, external validation with receiver operating characteristic (ROC) analysis was performed using a second series from 2019 to 2020.

Results

Postoperative DI occurred in 40 of 159 included patients. Twelve patients required inpatient desmopressin treatment and 20 patients needed desmopressin prescription after discharge. The potential predictors of requiring any desmopressin use included higher peak sodium (Na) level (p = 0.007), lower minimum Na level (p = 0.043), and higher peak urine output (p = 0.006), but these were not supported by external validation. The predictors of requiring desmopressin after discharge included higher peak Na (p = 0.040) and minimum Na levels (p = 0.048), which were supported by external ROC validation showing areas under curve of 0.787, 0.611, and 0.898 for peak Na (p = 0.036), minimum Na (p = 0.460), and peak Na – minimum Na levels (p < 0.001), respectively. A criterion of peak Na ≥ 150 mmol/L or peak Na – minimum Na ≥ 10 predicted the need of desmopressin prescription after discharge. A postoperative management algorithm was proposed.

Conclusion

The required treatments for patients with postoperative DI following endoscopic sellar surgery are heterogenous. Elevated peak Na and large peak Na—minimum Na levels in the perioperative period predicted requiring desmopressin after hospital discharge. Patients with peak Na <150 mmol/L and peak Na—minimum Na <10 can be safely discharged without desmopressin prescription.

Predictive factors of postoperative diabetes insipidus in 333 patients undergoing transsphenoidal surgery for non-functioning pituitary adenoma

PURPOSE

Diabetes insipidus (DI) following transsphenoidal surgery (TSS) is a common complication. Although postoperative DI often occurs in patients with craniopharyngioma and Rathke's cleft cyst, postoperative DI in patients with non-functioning pituitary adenoma (NFPA) has not been fully examined. We clarified the clinical characteristics and magnetic resonance imaging (MRI) findings predicting postoperative DI in NFPAs.

METHODS

A total of 333 patients undergoing initial TSS for NFPA were included in this retrospective study. Hyperintensity (HI) in the posterior pituitary lobe was evaluated on preoperative T1-weighted MRI. Based on the findings of HI patients were divided into three groups as follows: HI was not detected (Disappearance group), HI located intrasellarly (Intrasellar group), and HI located suprasellarly (Suprasellar group).

RESULTS

The overall rate of DI was 21.9%, including permanent DI in 0.6%. DI occurred at postoperative day 1 (72.6%) or day 2 (19.2%) and improved within 7 days in most cases (87.7%). Univariable and multivariable analyses showed that the predictive factors of DI were a younger age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95-0.99, P = 0.0037) and larger tumor diameter (OR 1.04, 95% CI 1.01-1.08, P = 0.0155). The rate of DI was highest in the Disappearance group (43.8%) followed by the Intrasellar group (26.0%). The OR was 2.17 in the Intrasellar group compared with the Suprasellar group (95% CI 1.17-4.02, P = 0.0141).

CONCLUSIONS

Factors predicting DI following TSS for NFPA were a younger age, larger tumor size, and the location of intrasellar HI on preoperative T1-weighted MRI.

Transsphenoidal Surgery of Giant Pituitary Adenoma: Results and Experience of 239 Cases in A Single Center

BACKGROUND

Transsphenoidal surgery (TSS) is first-line treatment for giant pituitary adenomas (PAs). Although PA is a benign neuroendocrine tumor that originates from adenohypophysial cells, the surgical outcomes and prognosis of giant PAs differ significantly due to multiple factors such as tumor morphology, invasion site, pathological characteristics and so on. The aim of this study was to evaluate surgical outcomes of giant PAs in a single-center cohort.

METHODS

The clinical features and outcomes of 239 patients with giant PA who underwent sphenoidal surgery at the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2015 to October 2021 were collected from medical records. The basic clinical information (age, gender, function etc.), surgical procedure, imaging features (maximum diameter, invasion characteristics, tumor shape etc.) and histopathological characteristics (pathological results, Ki-67, P53 etc.) were retrospectively reviewed. SPSS 25.0 and Stata 12.0 software were used for statistical analysis.

RESULTS

A total of 239 patients with giant PAs underwent TSS, of which 168 surgeries (70.29%) were endoscopic endonasal transsphenoidal (EETS) and 71 (29.71%) were microscopic transsphenoidal (MTS). The mean preoperative maximum diameter in the cohort was 45.64 mm. Gross-total resection was achieved in 46 patients (19.25%), near-total in 56 (23.43%), subtotal in 68 (28.45%), and partial in 69 (28.87%) patients. The maximum tumor diameter and Knosp grade were the significant factors that limited the extent of the resection of giant PAs. A total of 193 patients (80.75%) experienced surgical complications, and the most common complications were postoperative diabetes insipidus (DI) (91, 38.08%), intracranial infection (36, 15.06%) and cerebrospinal fluid (CSF) leaks (37, 15.48%). In addition, there was a significant difference in the incidence of CSF leaks between the neuroendoscopy group and the microscopic group (P < 0.05).

CONCLUSION

The management of giant PAs remains a therapeutic challenge due to their large size and postoperative complications. The maximum diameter and Knosp grade of giant PAs significantly limited the extent of resection, which warrants a reasonable surgical plan.

Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients

PURPOSE

To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis.

METHODS

All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery.

RESULTS

Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients.

CONCLUSION

This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.

Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score

OBJECTIVE

To identify risk factors for the development of postoperative diabetes insipidus (DI) in a modern cohort of endoscopic endonasal transsphenoidal surgery.

METHODS

Analysis of prospectively collected data of 449 consecutive patients operated on for anterior skull base pathology. DI was defined as a polyuria (> 250 ml/h for ≥ 2 consecutive hours) polydipsia syndrome associated with hypotonic urine with or without hypernatraemia. Multivariate logistic regression was used to identify predictors of postoperative DI. A simple scoring system was then created.

RESULTS

Postoperative DI occurred in 46 (10.2%) patients. The development of DI did not affect quality of life. Predictors of DI on multivariate analysis included suprasellar extension (OR 2.2; p = 0.04), age < 50 years (OR 2.8; p = 0.003), craniopharyngioma histology (OR 6.7; p = 0.002), and Kelly grade 3 intraoperative CSF leak (OR 2.1; p = 0.04). The SALT score was created based on these characteristics, with one point awarded for each feature present, and predicted DI with fair to good predictive value in our cohort (AUROC 0.735 (95%CI 0.65-0.82)). The rates of postoperative DI were 4.0%, 6.5%, 15.0%. 36.8% and 85.7% for SALT scores of zero, one, two, three, and four, respectively.

CONCLUSIONS

The SALT score predicts postoperative DI with fair to good accuracy, and now requires prospective external validation. Improved prediction of DI could optimize resource allocation and facilitate individualised preoperative patient counselling. We also provide our algorithm for diagnosis and treatment of DI.

Intraoperative Cerebrospinal Fluid Leak Graded by Esposito Grade Is a Predictor for Diabetes Insipidus After Endoscopic Endonasal Pituitary Adenoma Resection

BACKGROUND

Diabetes insipidus (DI) is a well-known complication of transsphenoidal surgery. However, the risk factors for DI remain controversial.

METHODS

We conducted a retrospective study of patients who underwent endoscopic transsphenoidal surgery for pituitary adenoma at our institution during a 5-year period. The patients were divided into a DI group and a non-DI group. Logistic regression analyses were used to identify risk factors for postoperative DI. In subgroup analysis, the DI group was divided into transient DI and permanent DI groups, and perioperative factors were compared between groups.

RESULTS

Of 101 patients, 58 were in the non-DI group (57.4%) and 43 were in the DI group (42.6%). Permanent DI occurred in 7 patients (6.9%). In univariate analyses, statistically significant risk factors were suprasellar extension, tumor functionality, and intraoperative cerebrospinal fluid leaks by Esposito grade. In multivariate logistic regression analysis, Esposito grade was the only statistically significant risk factor (P = 0.015). The frequency of DI increased as the Esposito grade increased (P = 0.0002 for the trend). In subgroup analysis, postoperative nadir sodium concentration was lower in the permanent DI group (128.1 ± 2.78 mmol/L) than in the transient DI group (135 ± 1.22 mmol/L; P = 0.035), and the optimal cutoff value was 124.5 mmol/L, with a sensitivity of 57.1% and a specificity of 91.7% (area under the curve = 0.76, P = 0.034).

CONCLUSIONS

Intraoperative cerebrospinal fluid leak by Esposito grade is associated with postoperative DI. These data can be applied to help identify high-risk patients who need more aggressive follow-up and fluid management.

Changes in copeptin levels before and 3 months after transsphenoidal surgery according to the presence of postoperative central diabetes insipidus

Copeptin levels reflect arginine vasopressin (AVP) release from the hypothalamus. Pituitary surgery often impairs AVP release and results in central diabetes insipidus (CDI). Here, we aimed to investigate how serum copeptin level changes 3 months after pituitary surgery and whether it has a diagnostic value for postoperative permanent CDI. Consecutive patients who underwent endoscopic transsphenoidal surgery at a single tertiary hospital were recruited. Serum copeptin levels were measured preoperatively and 3 months postoperatively. Among 88 patients, transient and permanent CDI occurred in 17 (19.3%) and 23 (26.1%), respectively. Three-month postoperative copeptin levels significantly declined from preoperative levels in permanent CDI group (P < 0.001, percentage difference =  - 42.2%) and also in the transient CDI group (P = 0.002, - 27.2%). Three months postoperative copeptin level < 1.9 pmol/L under normal serum sodium levels was the optimal cutoff value for diagnosing permanent CDI with an accuracy of 81.8%, while 3-month postoperative copeptin level ≥ 3.5 pmol/L excluded the CDI with a negative predictive value of 100%. Conclusively, 3 months postoperative copeptin levels significantly decreased from preoperative levels in the transient CDI group as well as the permanent CDI group. Three-month postoperative copeptin levels ≥ 3.5 pmol/L under normal serum sodium levels may be diagnostic for excluding postoperative CDI.

Neural network modeling for prediction of recurrence, progression, and hormonal non-remission in patients following resection of functional pituitary adenomas

PURPOSE

Functional pituitary adenomas (FPAs) cause severe neuro-endocrinopathies including Cushing's disease (CD) and acromegaly. While many are effectively cured following FPA resection, some encounter disease recurrence/progression or hormonal non-remission requiring adjuvant treatment. Identification of risk factors for suboptimal postoperative outcomes may guide initiation of adjuvant multimodal therapies.

METHODS

Patients undergoing endonasal transsphenoidal resection for CD, acromegaly, and mammosomatotroph adenomas between 1992 and 2019 were identified. Good outcomes were defined as hormonal remission without imaging/biochemical evidence of disease recurrence/progression, while suboptimal outcomes were defined as hormonal non-remission or MRI evidence of recurrence/progression despite adjuvant treatment. Multivariate regression modeling and multilayered neural networks (NN) were implemented. The training sets randomly sampled 60% of all FPA patients, and validation/testing sets were 20% samples each.

RESULTS

348 patients with mean age of 41.7 years were identified. Eighty-one patients (23.3%) reported suboptimal outcomes. Variables predictive of suboptimal outcomes included: Requirement for additional surgery in patients who previously had surgery and continue to have functionally active tumor (p = 0.0069; OR = 1.51, 95%CI 1.12-2.04), Preoperative visual deficit not improved after surgery (p = 0.0033; OR = 1.12, 95%CI 1.04-1.20), Transient diabetes insipidus (p = 0.013; OR = 1.27, 95%CI 1.05-1.52), Higher MIB-1/Ki-67 labeling index (p = 0.038; OR = 1.08, 95%CI 1.01-1.15), and preoperative low cortisol axis (p = 0.040; OR = 2.72, 95%CI 1.06-7.01). The NN had overall accuracy of 87.1%, sensitivity of 89.5%, specificity of 76.9%, positive predictive value of 94.4%, and negative predictive value of 62.5%. NNs for all FPAs were more robust than for CD or acromegaly/mammosomatotroph alone.

CONCLUSION

We demonstrate capability of predicting suboptimal postoperative outcomes with high accuracy. NNs may aid in stratifying patients for risk of suboptimal outcomes, thereby guiding implementation of adjuvant treatment in high-risk patients.

Role of pituitary stalk and gland radiological status on endocrine function and outcome after endoscopic transsphenoidal surgery for non-functioning pituitary adenomas

PURPOSE

To investigate endocrine function changes after non-functioning pituitary adenomas (NFPA) transsphenoidal surgery and to search for predictors of hypopituitarism resolution and development.

METHODS

We included 117 patients with NFPA who underwent endoscopic transsphenoidal surgery from 2005 to 2019 by two neurosurgeons. Twenty-one patients were excluded because of previous pituitary surgery or radiotherapy. We assessed symptoms at diagnosis, tumour volume, tumour removal, hormonal status at diagnosis, hormonal outcomes at 2- and 12-month follow-up, and complications. Pituitary stalk and gland MRI status (visible or not) were included, and it theirs association to hormonal function was studied for the first time, to our knowledge.

RESULTS

Pituitary gland visualization was more frequent in those patients who showed a smaller number of axes affected at 12 months (p = 0.011). Pituitary stalk status showed no association to hormonal function. The hormonal normalization rate at 12 months was 13%. The endocrine improvement rate at 12 months was 16.7%. Worsening of hormonal function occurred in 19.8% of patients. Younger age was associated to hormonal improvement (p = 0.004). Higher preoperative tumour volume (p = 0.015) and absence of gross total resection (GTR) (p = 0.049) were associated with worsening in at least one hormonal axis after surgery.

CONCLUSIONS

Pituitary gland visibility was higher in those patients who showed better hormonal outcomes. Assessment of initial hormonal function and outcome after surgery regarding pituitary stalk status showed no significant association. Higher preoperative tumour volumes and absence of GTR were associated to postoperative endocrine function worsening, while younger age was associated to its improvement.

Is it possible to predict the development of diabetes insipidus after pituitary surgery? Study of 241 endoscopic transsphenoidal pituitary surgeries

PURPOSE

To identify presurgical and surgical factors associated with the development of diabetes insipidus (DI) after pituitary adenoma (PA) resection through an endoscopic endonasal transsphenoidal approach.

METHODS

Data from 231 patients with functioning and non-functioning PAs who underwent an endoscopic endonasal transsphenoidal approach in the last ten years.

RESULTS

231 patients with 241 pituitary surgeries were included. Eighty-five percent harbored macroadenomas and 38.1% of them were invasive. After pituitary surgery, 12.5% (n = 30) developed transient DI and 5.0% (n = 12) permanent DI. The global risk of DI was higher in patients younger than 65 years (OR = 2.94, p = 0.029), with total tumoral resection (OR = 2.86, p = 0.007) and with diaphragm opening during pituitary resection (OR = 3.63, p = 0.0003). Once postoperative DI developed, the risk of permanent DI increased in those patients with larger PA (OR = 1.07 for each mm of craniocaudal diameter, p = 0.020), especially in those greater than 30 mm (OR = 8.33, p = 0.004). Moreover, diaphragm opening during pituitary resection (OR = 28.3, p = 0.018) predicted long-term DI independently of pituitary tumor size. The risk of permanent DI increased as PA craniocaudal diameter increased (r = 0.20, p = 0.002).

CONCLUSION

In patients with PAs younger than 65 years, in whom diaphragm has been opened during pituitary surgery and/or with a total tumor resection, special hydric balance monitoring should be maintained in the postoperative period due to the increased risk of developing DI. The risk of permanent DI increases as PA craniocaudal diameter increased.

Clinical characteristics and outcomes of null-cell versus silent gonadotroph adenomas in a series of 1166 pituitary adenomas from a single institution

OBJECTIVE

Nonfunctioning pituitary adenomas present without biochemical or clinical signs of hormone excess and are the second most common type of pituitary adenomas. The 2017 WHO classification scheme of pituitary adenomas differentiates null-cell adenomas (NCAs) and silent gonadotroph adenomas (SGAs). The present study sought to highlight the differences in patient characteristics and clinical outcomes between NCAs and SGAs.

METHODS

The records of 1166 patients who underwent transsphenoidal surgery for pituitary adenoma between 2012 and 2019 at a single institution were retrospectively reviewed. Patient demographics and clinical outcomes were collected.

RESULTS

Of the overall pituitary adenoma cohort, 12.8% (n = 149) were SGAs and 9.2% (n = 107) NCAs. NCAs were significantly more common in female patients than SGAs (61.7% vs 26.8%, p < 0.001). There were no differences in patient demographics, initial tumor size, or perioperative and short-term clinical outcomes. There was no significant difference in the amount of follow-up between patients with NCAs and those with SGAs (33.8 months vs 29.1 months, p = 0.237). Patients with NCAs had significantly higher recurrence (p = 0.021), adjuvant radiation therapy usage (p = 0.002), and postoperative diabetes insipidus (p = 0.028). NCA pathology was independently associated with tumor recurrence (HR 3.64, 95% CI 1.07-12.30; p = 0.038), as were cavernous sinus invasion (HR 3.97, 95% CI 1.04-15.14; p = 0.043) and anteroposterior dimension of the tumor (HR 2.23, 95% CI 1.09-4.59; p = 0.030).

CONCLUSIONS

This study supports the definition of NCAs and SGAs as separate subgroups of nonfunctioning pituitary adenomas, and it highlights significant differences in long-term clinical outcomes, including tumor recurrence and the associated need for adjuvant radiation therapy, as well as postoperative diabetes insipidus. The authors also provide insight into independent risk factors for these outcomes in the adenoma population studied, providing clinicians with additional predictors of patient outcomes. Follow-up studies will hopefully uncover mechanisms of biological aggressiveness in NCAs and associated molecular targets.

Cephalocaudal tumor diameter is a predictor of diabetes insipidus after endoscopic transsphenoidal surgery for non-functioning pituitary adenoma

PURPOSE

Diabetes insipidus (DI) develops commonly after endoscopic transsphenoidal surgery (ETS). We retrospectively investigated the incidence, onset, duration and predictors of DI after ETS in patients with non-functioning pituitary adenoma (NFPA).

METHODS

A total of 168 patients who underwent ETS to remove NFPAs were included. Various perioperative data on demographics, comorbidities, previous treatments, perioperative hormone deficiencies, tumor characteristics, surgery, anesthesia, intraoperative fluid balance, perioperative laboratory findings, postoperative complications, readmission and hospital length of stay were collected and analyzed. Patients were diagnosed with DI and treated with desmopressin when they showed urine output > 5 mL/kg/hr with a serum sodium concentration > 145 mmol/L or an increase ≥ 3 mmol/L in serum sodium concentration between two consecutive tests after surgery. DI was considered permanent when desmopressin was prescribed for > 6 months after surgery.

RESULTS

Seventy-seven (45.8%) patients experienced postoperative DI and 10 (6.0%) patients suffered from permanent DI. The median onset of DI and the median duration of transient DI were postoperative day 1 and 5 days, respectively. In multivariable logistic regression analysis, cephalocaudal tumor diameter (odds ratio [95% confidence interval] 2.59 [1.05-6.36], P = 0.038) was related to postoperative DI. In receiver operating characteristic analysis, its area under the curve was 0.68 (95% confidence interval 0.59-0.76, P < 0.001). Its optimal cutoff value that maximized the sum of sensitivity and specificity for postoperative DI was 2.7 cm.

CONCLUSIONS

Postoperative DI was observed in 45.8% of patients undergoing ETS to remove NFPAs. A large cephalocaudal tumor diameter was predictive of postoperative DI in such patients.

Postoperative diabetes insipidus: how to define and grade this complication?

PURPOSE

Although transient diabetes insipidus (DI) is the most common complication of pituitary surgery, there is no consensus on its definition. Polyuria is the most overt symptoms of DI, but can also reflect several physiological adaptive mechanisms in the postoperative phase. These may be difficult to distinguish from and might coincide with DI. The difficulty to distinguish DI from other causes of postoperative polyuria might explain the high variation in incidence rates. This limits interpretation of outcomes, in particular complication rates between centers, and may lead to unnecessary treatment. Aim of this review is to determine a pathophysiologically sound and practical definition of DI for uniform outcome evaluations and treatment recommendations.

METHODS

This study incorporates actual data and the experience of our center and combines this with a review of literature on pathophysiological mechanisms and definitions used in clinical studies reporting of postoperative DI.

RESULTS

The occurrence of excessive thirst and/or hyperosmolality or hypernatremia are the best indicators to discriminate between pathophysiological symptoms and signs of DI and other causes. Urine osmolality distinguishes DI from osmotic diuresis.

CONCLUSIONS

To improve reliability and comparability we propose the following definition for postoperative DI: polyuria (urine production > 300 ml/hour for 3 h) accompanied by a urine specific gravity (USG) < 1.005, and at least one of the following symptoms: excessive thirst, serum osmolality > 300 mosmol/kg, or serum sodium > 145 mmol/L. To prevent unnecessary treatment with desmopressin, we present an algorithm for the diagnosis and treatment of postoperative DI.

Perioperative Diabetes Insipidus Caused by Anesthetic Medications: A Review of the Literature

Diabetes insipidus (DI) is an uncommon perioperative complication that can occur secondary to medications or surgical manipulation and can cause significant hypovolemia and electrolyte abnormalities. We reviewed and evaluated the current literature and identified 24 cases of DI related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine, and opioids. This review summarizes the case reports and frequency of DI with each medication and presents possible pathophysiology. Medication-induced DI should be included in the differential diagnosis when intraoperative polyuria is identified. Early identification, removal of the agent, and treatment of intraoperative DI are critical to minimize complications.

Neuroimaging of central diabetes insipidus

Central diabetes insipidus (CDI) occurs secondary to deficient synthesis or secretion of arginine vasopressin peptide from the hypothalamo-neurohypophyseal system (HNS). It is characterized by polydipsia and polyuria (urine output >30mL/kg/day in adults and >2l/m²/24h in children) of dilute urine (<250mOsm/L). It can result from any pathology affecting one or more components of the HNS including the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei, and median eminence of the hypothalamus, infundibulum, stalk or the posterior pituitary gland. MRI is the imaging modality of choice for evaluation of the hypothalamic-pituitary axis (HPA), and a dedicated pituitary or sella protocol is essential. CT can provide complimentary diagnostic information and is also of value when MRI is contraindicated. The most common causes are benign or malignant neoplasia of the HPA (25%), surgery (20%), and head trauma (16%). No cause is identified in up to 30% of cases, classified as idiopathic CDI. Knowledge of the anatomy and physiology of the HNS is crucial when evaluating a patient with CDI. Establishing the etiology of CDI with MRI in combination with clinical and biochemical assessment facilitates appropriate targeted treatment. This chapter illustrates the wide variety of causes and imaging correlates of CDI on neuroimaging, discusses the optimal imaging protocols, and revises the detailed neuroanatomy required to interpret these studies.

Postoperative Copeptin as a Biomarker for Development of Diabetes Insipidus Following Hypothalamic-Pituitary Surgery

OBJECTIVE

Copeptin is a surrogate marker of arginine vasopressin release with better stability and simplicity of measurement. Postoperative copeptin levels may guide clinicians in stratifying patients who need close monitoring of fluid balance. The objective is to determine whether copeptin is a predictive marker of postoperative diabetes insipidus (DI).

METHODS

This is a prospective diagnostic study. Patients who underwent neurosurgical intervention of the sellar-suprasellar regions were recruited. Serum copeptin levels were measured before and after surgery, within 24 hours. Logistic regression analysis and diagnostic performance measures were calculated to determine the relationship between postoperative copeptin levels and DI.

RESULTS

Of 82 patients, 26 (31.7%) developed postoperative DI, with 7 patients (8.5%) having permanent DI. The samples for copeptin measurement were taken at 13 ± 2.1 hours postoperatively. From the receiver operating characteristic analysis, low postoperative copeptin levels (<2.5 pmol/L) demonstrated an acceptable ability to predict DI (area under the curve, 0.72; 95% CI, 0.60-0.84). Discriminative power was stronger in the permanent DI group (area under the curve, 0.82; 95% CI, 0.64-1.00). Postoperative copeptin levels <2.5 pmol/L were associated with DI (specificity > 91%). However, postoperative copeptin levels >20 pmol/L were rarely associated with DI, with a negative predictive value of 100%.

CONCLUSIONS

In patients undergoing sellar-suprasellar interventions, low postoperative copeptin levels within the first postoperative day predict postoperative DI, whereas high levels exclude it. Copeptin measurement should be applied in the clinical practice of postoperative care in patients following hypothalamic-pituitary surgery. This study may expand the potential use of copeptin, including in the Asian population.

Pituitary gland recovery following fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenoma: results of a prospective multicenter study

OBJECTIVE

Recovery from preexisting hypopituitarism after transsphenoidal surgery for pituitary adenoma is an important outcome to investigate. Furthermore, pituitary function has not been thoroughly evaluated after fully endoscopic surgery, and benchmark outcomes have not been clearly established. Here, the authors characterize pituitary gland outcomes with a focus on gland recovery following endoscopic transsphenoidal removal of clinically nonfunctioning adenomas.

METHODS

This multicenter prospective study was conducted at 6 US pituitary centers among adult patients with nonfunctioning pituitary macroadenomas who had undergone endoscopic endonasal pituitary surgery. Pituitary gland function was evaluated 6 months after surgery.

RESULTS

The 177 enrolled patients underwent fully endoscopic transsphenoidal surgery; 169 (95.5%) of them were available for follow-up. Ninety-five (56.2%) of the 169 patients had had a preoperative deficiency in at least one hormone axis, and 20/95 (21.1%) experienced recovery in at least one axis at the 6-month follow-up. Patients with adrenal insufficiency were more likely to recover (10/34 [29.4%]) than were those with hypothyroidism (8/72 [11.1%]) or male hypogonadism (5/50 [10.0%]). At the 6-month follow-up, 14/145 (9.7%) patients had developed at least one new deficiency. The study did not identify any predictors of gland recovery (p ≥ 0.20). Permanent diabetes insipidus was observed in 4/166 (2.4%) patients. Predictors of new gland dysfunction included a larger tumor size (p = 0.009) and Knosp grade 3 and 4 (p = 0.051).

CONCLUSIONS

Fully endoscopic pituitary surgery resulted in improvement of pituitary gland function in a substantial minority of patients. The deficiency from which patients were most likely to recover was adrenal insufficiency. Overall rates of postoperative permanent diabetes insipidus were low. This study provides multicenter benchmark neuroendocrine clinical outcome data for the endoscopic technique.

Low-dose ACTH test for evaluation of hypothalamus-pituitary-adrenal axis preoperatively and 3-month follow-up in non-functioning pituitary adenomas

BACKGROUND

Peri-operative glucocorticoids are routinely administered to patients undergoing trans-sphenoidal surgery for non-functional pituitary adenomas (NFPA) irrespective of hypothalamus-pituitary-adrenal (HPA) axis status.

PURPOSE

Evaluation of HPA axis before and 12 weeks after endoscopic trans-sphenoidal adenomectomy (E-TSA) utilizing low-dose (1 μg) ACTH stimulation test (LDACTH) to determine the need for glucocorticoid administration in patients with NFPA. We also determined the factors that can predict occurrence of hypocortisolism at 12 weeks after surgery.

METHODS

Sixty-three consecutive patients with NFPA requiring surgical excision were enrolled in this study. Glucocorticoids were administered to patients with demonstrable hypocortisolism [preoperative peak cortisol < 16 μg/dL during LDACTH test, postoperative day 3 (POD-3) 0800 hrs Cortisol < 8 μg/dL or stimulated cortisol (LDACTH) < 16 μg/dL at 12 weeks].

RESULTS

Hypocortisolism was present in 43 patients (68.2%) pre-operatively and persisted in 33 patients (52.4%) on POD-3. Thirty-three patients (52.4%) had hypocortisolism at 12 weeks after surgery. Eleven patients (17.4%) did not require glucocorticoids during the entire study period and 30 patients (47.6%) did not require glucocorticoids after 3 months. None of the patients developed adrenal crisis during the study. Hypocortisolism on the third post-operative day was the single significant predictor of hypocortisolism at 12 weeks after the surgery. There was a significant correlation between POD-3 0800 hrs cortisol ≥ 8μg/dL and stimulated cortisol (LDACTH) ≥16μg/dL at 12 weeks (r = 0.62, p < 0.0001). POD-3 0800 hrs cortisol ≥ 8 μg/dL had 73% sensitivity and 79% specificity in predicting eucortisolism at 12 weeks.

CONCLUSIONS

HPA function is preserved in significant proportion of NFPA patients undergoing E-TSA. Perioperative glucocorticoids should be given only in patients with demonstrable preoperative hypocortisolism on 1 μg ACTH test. Postoperative day 3 0800 hrs cortisol is a reasonable predictor of HPA axis status at 12 weeks after surgery.

Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma

OBJECTIVE

Life expectancy has increased over the past century, causing a shift in the demographic distribution toward older age groups. Elderly patients comprise up to 14% of all patients with pituitary tumors, with most lesions being nonfunctioning pituitary adenomas (NFPAs). Here, the authors evaluated demographics, outcomes, and postoperative complications between nonelderly adult and elderly NFPA patients.

METHODS

A retrospective review of 908 patients undergoing transsphenoidal surgery (TSS) for NFPA at a single institution from 2007 to 2019 was conducted. Clinical and surgical outcomes and postoperative complications were compared between nonelderly adult (age ≥ 18 and ≤ 65 years) and elderly patients (age > 65 years).

RESULTS

There were 614 and 294 patients in the nonelderly and elderly groups, respectively. Both groups were similar in sex (57.3% vs 60.5% males; p = 0.4), tumor size (2.56 vs 2.46 cm; p = 0.2), and cavernous sinus invasion (35.8% vs 33.7%; p = 0.6). Regarding postoperative outcomes, length of stay (1 vs 2 days; p = 0.5), extent of resection (59.8% vs 64.8% gross-total resection; p = 0.2), CSF leak requiring surgical revision (4.3% vs 1.4%; p = 0.06), 30-day readmission (8.1% vs 7.3%; p = 0.7), infection (3.1% vs 2.0%; p = 0.5), and new hypopituitarism (13.9% vs 12.0%; p = 0.3) were similar between both groups. Elderly patients were less likely to receive adjuvant radiation (8.7% vs 16.3%; p = 0.009), undergo future reoperation (3.8% vs 9.5%; p = 0.003), and experience postoperative diabetes insipidus (DI) (3.7% vs 9.4%; p = 0.002), and more likely to have postoperative hyponatremia (26.7% vs 16.4%; p < 0.001) and new cranial nerve deficit (1.9% vs 0.0%; p = 0.01). Subanalysis of elderly patients showed that patients with higher Charlson Comorbidity Index scores had comparable outcomes other than higher DI rates (8.1% vs 0.0%; p = 0.006). Elderly patients’ postoperative sodium peaked and troughed on postoperative day 3 (POD3) (mean 138.7 mEq/L) and POD9 (mean 130.8 mEq/L), respectively, compared with nonelderly patients (peak POD2: mean 139.9 mEq/L; trough POD8: mean 131.3 mEq/L).

CONCLUSIONS

The authors’ analysis revealed that TSS for NFPA in elderly patients is safe with low complication rates. In this cohort, more elderly patients experienced postoperative hyponatremia, while more nonelderly patients experienced postoperative DI. These findings, combined with the observation of higher DI in patients with more comorbidities and elderly patients experiencing later peaks and troughs in serum sodium, suggest age-related differences in sodium regulation after NFPA resection. The authors hope that their results will help guide discussions with elderly patients regarding risks and outcomes of TSS.

Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas

INTRODUCTION

Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas.

AREAS COVERED

We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019.

EXPERT OPINION

Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.