Surgical indications for and limitations of staged transsphenoidal surgery for large pituitary tumors

Surgical indications and limitations of transsphenoidal surgery and intentionally staged transsphenoidal surgery for large pituitary tumors were investigated by retrospective analysis of the surgical and neuroradiological findings of 22 patients with large tumor and suprasellar extension. Twelve patients underwent intentionally staged transsphenoidal surgery, and 10 underwent combined transsphenoidal and transcranial surgeries. Successful removal by intentionally staged surgery required descent of the suprasellar part following the first transsphenoidal surgery. Analysis showed that a smooth suprasellar extension and/or soft tumor are indications for intentionally staged transsphenoidal surgery even in patients with small sella. However, lobulated suprasellar extension, fibrous and firm tumor without descent, and small sella with normal pituitary gland located at the bottom of the sella are contraindications for staged transsphenoidal surgery. The first transsphenoidal surgery is always indicated to achieve histological confirmation and decompression of optic nerves. Transcranial surgery should be attempted instead of repeated transsphenoidal surgeries when the residual tumor does not descend following the first transsphenoidal surgery.