Utilizing In-Situ Bone Flap for Skull Base Reconstruction in Endoscopic Surgery of Invasive Pituitary Adenoma: A Novel Approach

doi:10.21203/rs.3.rs-4334254/v1

Objective: To evaluate the efficacy of in-situ bone flap (ISBF) repositioning technique in skull base reconstruction for invasive pituitary adenoma (IPA) via endoscopic endonasal approach (EEA).

Method: In a retrospective study spanning the years 2018 to 2023, we investigated the efficacy of in-situ bone flap (ISBF) repositioning technique in patients with invasive pituitary adenoma (IPA) who underwent endoscopic endonasal surgery (EEA). Among the 115 patients included in the study, 65 were assigned to the group, while the remaining 55 were categorized into the non-ISBF group. Comprehensive data on patients’ basic characteristics, surgical situation, and clinical outcomes were meticulously collected and analyzed.

Results: In our study, we observed postoperative cerebrospinal fluid (CSF) leakage in 1 out of 65 patients in the ISBF group, while 8 out of 50 patients in the non-ISBF group experienced this complication, indicating a significant difference (P<0.05).

Conclusion: The ISBF repositioning technique emerges as an effective and feasible method for skull base reconstruction in patients who have underwent EEA surgery for IPA. Notably, this technique significantly reduces the incidence of postoperative CSF leakage.

invasive

aggressive

skull base reconstruction

pituitary adenoma

endoscopic

transsphenoidal

CSF leakage

in-situ bone flap

rigid

Pituitary adenomas(PAs), ranking as the third most prevalent neurological tumors following gliomas and meningiomas, represent the predominant lesion within the sellar region.(1) Approximately 25% to 55% of pituitary adenomas manifest as invasive pituitary adenomas (IPAs; classified as Knosp III and IV). These IPAs are characterized by their invasion into adjacent tissues. Consequently, they are associated with a less favorable prognosis compared to their non-invasive counterparts.(2)

The Endoscopic Endonasal Approach (EEA) has emerged as the preferred surgical method for pituitary adenoma due to its advantages such as enhanced visualization, minimization of brain injury and neurovascular retraction, and reduced postoperative hospitalization duration, etc.(3) For EEA surgery, the importance of effective skull base reconstruction and comprehensive lesion resection cannot be overstated.(4) Addressing the skull base defect after surgery has consistently posed significant challenges in EEA surgery for PAs. Given that IPAs are often larger in size and infiltrate adjacent tissues, they result in a more extensive skull base defect during endoscopic surgery. This can subsequently escalate the risk of postoperative complications, including CSF and meningitis.(5) There is a paucity of research specifically investigating efficacious methods for skull base reconstruction in EEA surgery of IPAs. Consequently, the exploration of an effective technique is of paramount importance.

ISBF, characterized by the creation of a bone flap that can be subsequently repositioned and secured within its original location to repair a bony defect resulting from surgical procedures during EEA, has been proved effective in reducing the incidence of postoperative cerebrospinal fluid (CSF) leakage by several scholars.(6) However, the implication of this skull base reconstruction technique on patients with IPA remains ambiguous and necessitate additional exploration.

Our research indicates that the technique of ISBF reconstruction of the skull base is a safe and effective strategy for patients with IPA who have undergone EEA surgery.

Data collection and analysis:

We retrospectively collected data on patients with intraoperative pathological diagnosis of pituitary adenomas who underwent EEA surgery from 2018 to 2023. Among them, patients with preoperative imaging grades Knosp III and IV were included in the study. There are 115 patients met the inclusion criteria. 65 of these patients were categorized in the ISBF group by applying the ISBF repositioning technique during the surgery, and the remaining 50 patients were categorized as the non-ISBF group. Patients’ characteristics, surgical situation and clinical outcomes were evaluated and reviewed.

Surgical technique:

Before proceeding with the surgery, the patient underwent a comprehensive series of tests to exclude any contraindications to endoscopic endonasal approach (EEA) surgery. Magnetic Resonance Imaging (MRI) was employed to quantify the tumor size and delineate the extent of tumor invasion into peripheral neurovascular structures, including the optic nerve (ON), internal carotid artery (ICA), and cavernous sinus (CS), third ventricle (TV), among others. This information is crucial for the strategic planning and execution of the surgical procedure. Additionally, Computed Tomography (CT) was utilized to assess bony structure of sellar region and sphenoidal sinus.

Patients were intubated and positioned supine prior to the procedure. The surgical approach employed was the two-nostril/two-surgeon/four-hands technique, necessitating a posterior septectomy to enhance visualization. Throughout the surgery, the endoscope was secured to a pneumatic arm, providing a stable view and increased flexibility for the surgeon. Systematic preparation of the right thigh was undertaken for harvesting adipose tissue and fascia lata. To mitigate mucosal hemorrhage, the nasal cavity was packed with cottonoids soaked in adrenaline for 10 minutes. All patients received prophylactic antibiotics (cefuroxime sodium) 30 minutes before the incision. The anterior wall of sphenoidal sinus was carefully opened wide with microdrill with diamond burr to expose the sphenoidal sinus cavity and then sphenoid septation was removed with a Kerrison rongeur. During the process of accessing the pituitary fossa via the opening of the posterior wall of the sphenoidal sinus, an ISBF was harvested, in accordance with methods previously documented in the literature.(6) The coronal dimensions of the ISBF were typically confined between the bilateral ICA protuberances or between the bilateral optic protuberances. The sagittal dimensions of the bone flap were adjustable, contingent upon the location and size of the lesion. A high-speed micro drill was employed to perform an incision on the skull base bone along the dotted line demarcated in Fig1A, facilitating the extraction of the ISBF. After the incision, the bone flap was meticulously elevated from the dura mater (Fig1B). Throughout this procedure, it was imperative to preserve the integrity of the flap to mitigate the risk of inflicting damage to the adjacent tissues due to potential partial rupture and subsequent displacement of the flap following repositioning. Depending on the surgical requirements, the flap could either be folded to one side or temporarily excised via the nasal cavity.

After the resection of the tumor, the skull base reconstruction was performed. Different reconstruction techniques were used for the ISBF group and non-ISBF group.

In the non-ISBF group, a multilayer reconstruction was systematically employed. The first layer was constituted by adipose tissue, harvested from the patient’s thigh, which was then inserted into tumor cavity as an inlay graft. The subsequent layer was composed of the fascia lata, procured from an incision on the patient’s thigh, serving as an onlay graft. Finally, the synthetic dura was strategically positioned over the fascia lata graft, forming the third layer.

Within the introduction of the ISBF repositioning technique, we adopted a distinct reconstruction strategy for the selected patients in the ISBF group. The first layer was constituted by adipose tissue obtained from thigh, which was filled into tumor cavity to eliminate the dead space (Fig2A). Subsequently, the harvested ISBF was repositioned to cover the bone defect, forming the second layer, which was different from the approach to skull base reconstruction in patients in the non-ISBF group (Fig2B). The third layer was composed of the fasica lata from thigh, covering the ISBF (Fig2C). Finally, the synthetic dura was applied to cover the fasica lata as the fourth layer (Fig2D).

The surgeries were performed by an experienced surgeon (Prof. Peng Zhao) in the Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, thus minimizing the confounding factors brought by learning curve. (7) The prophylactic lumbar drainage was not routinely performed in the patients, because there is few evidence to support that adjunctive lumbar drainage significantly reduces the incidence of postoperative CSF leak. (8)

Postoperative management:

All patients underwent CT scan right after the surgery to determine if there was any postoperative intracranial hemorrhage. Following the surgical intervention, all patients underwent an enhanced MRI within a 48-hour period, aiming to ascertain the degree of tumor resection, evaluate the integrity of the skull base reconstruction, and assess potential damage inflicted upon the adjacent vascular and neural structures. All patients were subjected to a diagnostic ‘tilt test’ to identify the pressure of CSF rhinorrhea. During this test, patients were instructed to incline their head downward for 30 seconds. A persistent watery discharge from one or both nostrils typically signifies a failed repair resulting in CSF rhinorrhea. Conversely, a discharge resembling a thicker mucus-like substance does not indicate CSF rhinorrhea.(9) In addition, we conducted a series of chemical analyses, including the glucose oxidase assay and the β2-transferrin test, on the rhinorrhea samples collected from patients. These tests serve as valuable tools in the diagnostic process for CSF leakage.(10)

Patient characteristics:

The mean age of patients in the ISBF and non-ISBF groups was 52.13 and 51.90 years, respectively, with no significant difference observed (P = 0.264). The sex distribution across both groups was also statistically similar, with females constituting 47% (31/65) of the ISBF group and 58% (29/50) of the non-ISBF group (P = 0.273). In the non-ISBF group, two patients had a history of recurrent IPA and had previously been treated with EEA surgery. However, in the ISBF group, there were no cases of recurrent IPA. Statistical analysis revealed no significant difference between them (P = 0.364). The size of tumor, quantified as the maximum diameter derived from preoperative MRI, exhibited no significant disparity between the ISBF group (26.15 mm) and the non-ISBF group (29.67 mm) (P = 0.114). Furthermore, no significant differences were found between the ISBF and non-ISBF group in terms of medical history, including diabetes, hypertension, and coronary heart disease (CHD) (P = 0.686, 0.252, 1.00). The comparison of the Body Mass Index (BMI) between the two groups did not yield any statistically significant differences (P = 0.872). Lastly, the Knosp grade of each patient’s tumor was ascertained through preoperative enhanced MRI. Upon statistical analysis, the distribution of Knosp grades between the two groups did not demonstrate any significant disparity (P = 0.880). (Table1)

Surgical situation

Intraoperative CSF leakage was observed in 7 patients from the ISBF group and 8 patients from the non-ISBF group, yielding no statistically significant differences (P = 0.409). Notably, the mean operation time (OR time) for ISBF patients was 86 minutes, while the non-ISBF patients with a mean OR time of 98 minutes, with no significant disparity between the two groups (P = 0.144). (Table2)

Clinical outcomes:

Within the ISBF cohort, a singular instance of postoperative CSF leakage was observed (1/65, 1.53%), in contrast to the non-ISBF cohort where 8 instances were reported (8/50, 16%). This disparity in the incidence of CSF leakage between the two cohorts is statistically significant(P=0.012). The average length of postoperative hospitalization for patients within the ISBF group was 5.50 days, comparatively less than the 7.10 days noted in the non-ISBF group, despite this, the difference did not reach statistical significance (P=0.081). Postoperative polyuria was observed in 6 patients in the ISBF group (6 out of 65, 9.23%) and in 5 patients in the non-ISBF group (5 out of 50, 10%), with no significant differences noted. Two patients in the ISBF group developed postoperative meningitis (2 out of 65, 3.07%), compared to four patients in the non-ISBF group (4 out of 50, 8%). However, there was no statistical difference between the two groups (P=0.451). Lastly, none of the patients in either group experienced postoperative ON injury or ICA injury associated with ISBF harvesting and repositioning. (Table 3)

Table1 patient characteristics:

ISBF

Non-ISBF

P-value

No of patients

65

50

Sex

Male

34

21

0.273

Female

31

29

Age

52.13±14.199(years)

51.90±12.98(years)

0.246

Tumor size

26.15±9.40(mm)

29.67±11.90(mm)

0.114

BMI

24.92±4.69(kg/m²)

25.77±3.68(kg/m²)

0.872

Diabetes

Yes

No

5

58

6

44

0.686

Previous surgery

Yes

No

0

65

2

48

0.364

Radiotherapy history

Yes

No

0

65

0

50

—

Hypertension

Yes

No

13

50

15

35

0.252

CHD

Yes

No

1

64

0

50

1.00

Knosp grade

III

IV

41

9

54

11

0.880

Table2 surgical situation:

	ISBF	Non-ISBF	P-value
Intraoperative CSF leak Yes No	7 58	8 42	0.409

Operation time	86.35±33.79(min)	98.92±24.64(min)	0.144

Table3 clinical outcomes

ISBF

Non-ISBF

P-value

Postoperative CSF leakage

Yes

No

1

64

8

42

0.012

Postoperative epistaxis

Yes

No

1

64

0

50

1.00

Postoperative polyuria

Yes

No

6

59

5

45

1.00

Postoperative meningitis

Yes

No

2

63

4

46

0.451

Postoperative hospital stays

5.50±1.23(days)

7.10±1.84(days)

0.081

ICA injury

—

Yes

No

`0

65

0

50

ON injury

Yes

No

0

65

0

50

—

The repositioning of ISBF presents a dependable, expedient, and viable technique for skull base reconstruction in patients with IPA undergoing EEA surgery. Our preliminary study results indicate that the ISBF, when combined with a multilayer closure technique, significantly reduces the incidence of postoperative CSF leakage without increasing the occurrence of other complications.

Pituitary adenomas, benign in nature, account for a significant proportion, specifically 10% to 15%, of intracranial neoplasms. Despite their benign classification, a subset of these adenomas exhibits aggressive clinical behaviors, including rapid proliferation, invasion of surrounding tissues and resistance to conventional treatment.(11) The treatment of IPAs presents significant challenges due to their propensity to invade adjacent structures, including the cavernous sinus, dura, ICAs, ONs, TV, etc. The Knosp grade system was proposed in 1993 to classify pituitary adenoma according to the tumor anatomical relationship between ICAs. Within this system, grades III, IV are designated as IPAs. (12)

EEA surgery has become the first-line treatment for IPAs due to its advantages over microscopic surgery such as higher gross total resection (GTR) rate, more flexible maneuvering, better visualization, and better postoperative improvement of endocrine function, etc. (13, 14) Because IPAs invaded surrounding tissues, especially CS, the extended EEA approach was required to obtain better exposure and increase tumor resection rate. (15, 16) Previous studies noted that GTR of approximately 80% could be achieved utilizing extended EEA approach to remove IPAs, and high GTR rate tends to result in a better prognosis. (17, 18) The intraoperative assistance of Doppler ultrasound and magnetic neuronavigational system was essential to prevent damage to peripheral neurovascular structures during extended EEA surgery, especially the ICAs. (19, 20) Many scholars kept pushing the boundaries of indications for extended EEA approach. Certain distinct subtypes of pituitary adenomas such as dumbbell-shape tumors, pure suprasellar adenomas, fibrous adenomas, have historically proven refractory to conventional EEA surgery. However, these challenging cases can now be effectively addressed through the extended EEA approach. (21)

The successful execution of EEA surgery for IPAs hinges on two critical factors: the comprehensive resection of the tumor and effective skull base reconstruction.(4) Patients who have undergone EEA surgery are susceptible to postoperative complications associated with skull base defects, including CSF leak and meningitis, which may prolong hospitalization and lead to repeated surgery. (22)Patients with IPA are more susceptible to postoperative CSF leaks compared to patients with non-IPA. This increased risk is attributed to the larger tumor volume and the skull base defects that occur during surgery. (23, 24) Consequently, it is imperative to investigate more effective strategies for skull base reconstruction in EEA surgery for IPAs. The multilayer construction technique, which employs a combination of autologous and synthetic materials, is a prevalent practice in clinical settings. This method encompasses the use of free autografts, intranasal vascularized flaps, synthetic dural replacement grafts, and pedicled nasoseptal flaps. (4, 25) However, it is important to note that these materials are not fully capable of repairing bony defects of the skull base.

It has previously been suggested that rigid reconstruction of the skull base was unnecessary by some literature. (26) However, in recent years, an increasing number of scholars now advocate for a more affirmative stance regarding rigid reconstruction. Their rationale centers on the potential effectiveness of these procedures in mitigating complications associated with skull base defects, including acute or chronic headaches and pseudo meningoceles. (6) Various rigid reconstruction material has been explored and proposed recently, including bioabsorbable plate, hydroxyapatite cement, titanium mesh, autologous cartilage, etc. (27-30) Compared to these materials, ISBF has better histocompatibility, conforms better to the complex anatomy of the skull base, and has lower risk of infection and damage to adjacent tissues due to graft displacement. (31) Previous studies have demonstrated the effectiveness of applying ISBF for skull base reconstruction in EEA surgery. (31, 32) However, there are no studies exploring the role of ISBF in skull base reconstruction in EEA surgery for IPAs. Our investigation revealed that the ISBF technique was also effective in reducing the incidence of postoperative CSF leak in IPA patients.

Throughout the course of our investigation, we observed that patients within the ISBF group exhibited minimal sellar floor subsidence, as evidenced by postoperative MRI. We postulated that a reduced degree of sellar floor subsidence could potentially mitigate the extent of pituitary stalk traction, thereby diminishing the incidence of postoperative polyuria. This hypothesis appears to align with the lower incidence of postoperative polyuria observed in ISBF group patients (10.16%) compared to those in non-ISBF group (11.11%), despite the lack of statistical significance (P>0.05). However, it is imperative to note that this inference necessitates further validation through comprehensive and systematic studies.

We found the mean OR time was slightly longer in the non-ISBF group than in the ISBF group, although there was no significant difference between the two groups (P>0,05), however, it was still different from what we expected. Our study results prompt consideration of several factors. Firstly, despite our concerted efforts to minimize it, the learning curve inevitably influenced our findings, which is also a common limitation of retrospective studies. Furthermore, this outcome may imply that the additional procedure of acquiring and relocating the bone flap during surgery for patients in the ISBF group does not substantially extend the duration of the operation as the surgeon's proficiency advances.

Nonetheless, the ISBF repositioning technique is not without its constraints. Primarily, our clinical observations have indicated that this method is not universally applicable to all patients with IPA, and its implementation is contingent upon several criteria:1. The patient’s sphenoidal sinus must exhibit adequate pneumatization to ensure safe access to the bone flap.2. The bone flap must be devoid of adenoma invasion to circumvent the risk of tumor recurrence due to flap repositioning. These criteria have also been reported by previous scholars (6). In addition, this technique cannot be applied to patients with previous EEA surgery due to the absence of sellar floor bone. It is crucial to acknowledge that these limitations may introduce a potential bias, resulting in the ISBF group appearing to have less aggressive tumor invasiveness compared to the non-ISBF group.

Upon reviewing the existing literature, it was determined that several risk factors contribute to CSF leakage following EEA surgery. These factors encompass BMI, tumor size, incidence of intraoperative CSF leakage, perioperative radiotherapy, and diabetes mellitus, etc. Notably, BMI emerged as the primary risk factor, with a higher BMI correlating with an increased likelihood of postoperative CSF leakage (33, 34). We conducted a comprehensive collection and analysis of patient data pertaining to risk factors. Our analysis revealed no significant disparity between the two groups in terms of these risk factors (P>0.05) (Table1), thereby mitigating any bias these factors could potentially introduce to the study’s result.

Our study has all shortcomings associated with retrospective studies. Further multi-institutional prospective studies are needed to confirm the utility of ISBF repositioning in IPA patients undergoing EEA surgery.

ISBF (In Situ Bone Flap)

IPA (Invasive Pituitary Adenoma)

EEA (Endoscopic Endonasal Approach)

PA (Pituitary Adenoma)

CSF (Cerebrospinal Fluid)

ON (Optic Nerve)

ICA (Internal Carotid Artery)

CS (Cavernous Sinus)

TV (Third Ventricle)

CT (Computed Tomography)

BMI (Body Mass Index)

OR (Operation)

MRI (Magnetic resonance imaging)

GTR (gross total resection)

CS (Cavernous sinus)

Human Ethics and Consent to Participate declarations:

All procedures conducted in our studies adhered to the ethical guidelines set forth by the Institutional Review Board of the First Affiliated Hospital of Nanjing Medical University, in compliance with the principles outlined in the 1964 Helsinki Declaration and its subsequent amendments.

An informed consent form was signed by each participant.

Consent for publication:

not applicable

Availability of data and materials:

Data is provided within the manuscript or supplementary information files.

Funding declaration:

This research is financially supported by these following grants:

Outstanding Young and Middle-aged Talents Support Program of the First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital)
Jiangsu Province Capability Improvement Project through Science, Technology and Education, ZDXK202225

Competing interests:

The authors declare no conflicts of interest.

Authors’ contributions:

All authors made significant contributions to this retrospective study. PZ and DW conceptualized the study and designed its framework. PZ, DW, JL, and HC performed surgical procedures on the patients. KC, KY, and ZL were responsible for data collection, statistical analysis, and data interpretation. Additionally, they contributed to the preparation of figures and tables. KC, JL, KY, ZL, KD, and KX drafted the manuscript. HC, ZL, and KC corrected grammatical errors and refined the language of the manuscript. PZ, DW, and AL critically reviewed the initial draft and contributed to its finalization. Finally, all authors participated in reviewing the final version of the manuscript and consented to its submission for publication.

Acknowledgements:

not applicable

Aldahmani KM, Sreedharan J, Ismail MM, Philip J, Nair SC, Alfelasi M, et al. Prevalence and characteristics of sellar masses in the city of Al Ain, United Arab Emirates: 2010 to 2016. Annals of Saudi medicine. 2020;40(2):105-12.
Di Ieva A, Rotondo F, Syro LV, Cusimano MD, Kovacs K. Aggressive pituitary adenomas--diagnosis and emerging treatments. Nat Rev Endocrinol. 2014;10(7):423-35.
Zwagerman NT, Zenonos G, Lieber S, Wang WH, Wang EW, Fernandez-Miranda JC, et al. Endoscopic transnasal skull base surgery: pushing the boundaries. Journal of neuro-oncology. 2016;130(2):319-30.
Sigler AC, D'Anza B, Lobo BC, Woodard TD, Recinos PF, Sindwani R. Endoscopic Skull Base Reconstruction: An Evolution of Materials and Methods. Otolaryngologic clinics of North America. 2017;50(3):643-53.
Rahimli T, Hidayetov T, Rajabov T. Endoscopic Endonasal Approach to Multilobular Giant Pituitary Adenoma with Cavernous Sinus Invasion and Petroclival Extension. World Neurosurg. 2021;147:128-9.
Jin B, Wang XS, Huo G, Mou JM, Yang G. Reconstruction of skull base bone defects using an in situ bone flap after endoscopic endonasal transplanum-transtuberculum approaches. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2020;277(7):2071-80.
Park W, Nam DH, Kong DS, Lee KE, Park SI, Kim HY, et al. Learning curve and technical nuances of endoscopic skull base reconstruction with nasoseptal flap to control high-flow cerebrospinal fluid leakage: reconstruction after endoscopic skull base surgery other than pituitary surgery. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2022;279(3):1335-40.
Ahmed OH, Marcus S, Tauber JR, Wang B, Fang Y, Lebowitz RA. Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2017;156(1):52-60.
Straus D, Foster K, Zimmerman F, Frim D. Chiari drop attacks: surgical decompression and the role of tilt table testing. Pediatric neurosurgery. 2009;45(5):384-9.
Ziu M, Savage JG, Jimenez DF. Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. Neurosurgical focus. 2012;32(6):E3.
Raverot G, Burman P, McCormack A, Heaney A, Petersenn S, Popovic V, et al. European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas*. European Journal of Endocrinology. 2018;178(1):G1-G24.
Knosp E, Steiner E, Kitz K, Matula C. Pituitary Adenomas with Invasion of the Cavernous Sinus Space: A Magnetic Resonance Imaging Classification Compared with Surgical Findings. Neurosurgery. 1993;33(4):610-8.
Esquenazi Y, Essayed WI, Singh H, Mauer E, Ahmed M, Christos PJ, et al. Endoscopic Endonasal Versus Microscopic Transsphenoidal Surgery for Recurrent and/or Residual Pituitary Adenomas. World Neurosurg. 2017;101:186-95.
Ferreli F, Turri-Zanoni M, Canevari FR, Battaglia P, Bignami M, Castelnuovo P, et al. Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience. Rhinology. 2015;53(4):308-16.
Zhao B, Wei YK, Li GL, Li YN, Yao Y, Kang J, et al. Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases. Journal of neurosurgery. 2010;112(1):108-17.
Patel BK, Binu A, Stanley A, Shah SK, H RD, George T, et al. Large Pituitary Adenoma: Strategies to Maximize Volumetric Resection Using Endoscopic Endonasal Approaches and an Analysis of Factors Limiting Resection. World Neurosurg. 2022;167:e694-e704.
Zhang X, Fei Z, Zhang W, Zhang JN, Liu WP, Fu LA, et al. Endoscopic endonasal transsphenoidal surgery for invasive pituitary adenoma. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2008;15(3):241-5.
Rejane-Heim TC, Silveira-Bertazzo G, Carrau RL, Prevedello DM. Techniques and challenges of the expanded endoscopic endonasal sellar and parasellar approaches to invasive pituitary tumors. Acta neurochirurgica. 2021;163(6):1717-23.
Saeki N, Horiguchi K, Murai H, Hasegawa Y, Hanazawa T, Okamoto Y. Endoscopic endonasal pituitary and skull base surgery. Neurologia medico-chirurgica. 2010;50(9):756-64.
Pala A, Knoll A, Schneider M, Etzrodt-Walter G, Karpel-Massler G, Wirtz CR, et al. The Benefit of Intraoperative Magnetic Resonance Imaging in Endoscopic and Microscopic Transsphenoidal Resection of Recurrent Pituitary Adenomas. Current oncology (Toronto, Ont). 2022;29(1):392-401.
Di Maio S, Cavallo LM, Esposito F, Stagno V, Corriero OV, Cappabianca P. Extended endoscopic endonasal approach for selected pituitary adenomas: early experience. Journal of neurosurgery. 2011;114(2):345-53.
Werner MT, Yeoh D, Fastenberg JH, Chaskes MB, Pollack AZ, Boockvar JA, et al. Reconstruction of the Anterior Skull Base Using the Nasoseptal Flap: A Review. Cancers. 2023;16(1).
Munich SA, Fenstermaker RA, Fabiano AJ, Rigual NR. Cranial base repair with combined vascularized nasal septal flap and autologous tissue graft following expanded endonasal endoscopic neurosurgery. Journal of neurological surgery Part A, Central European neurosurgery. 2013;74(2):101-8.
Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, et al. Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. Journal of neurosurgery. 2007;107(4):713-20.
Xing M, Lv W, Liu P, Wang J, Gao W, Xu Y, et al. Multi-layer reconstruction of skull base after endoscopic transnasal surgery for invasive pituitary adenomas. Neurologia i neurochirurgia polska. 2023;57(2):160-8.
Eloy JA, Shukla PA, Choudhry OJ, Singh R, Liu JK. Assessment of frontal lobe sagging after endoscopic endonasal transcribriform resection of anterior skull base tumors: is rigid structural reconstruction of the cranial base defect necessary? The Laryngoscope. 2012;122(12):2652-7.
Lee SH, Ha CM, Hong SD, Choi JW, Seol HJ, Nam DH, et al. Clinical Impact of Hydroxyapatite on the Outcome of Skull Base Reconstruction for Intraoperative High-Flow CSF Leak: A Propensity Score Matching Analysis. Frontiers in oncology. 2022;12:906162.
Fermi M, Serafini E, Rosti A, Olive M, Alicandri-Ciufelli M, Sciarretta V, et al. Multilayer Anterior Skull Base Reconstruction with Cortical Rib Bone Graft: Preliminary Experience. World Neurosurg. 2023;179:e110-e8.
Al-Asousi F, Okpaleke C, Dadgostar A, Javer A. The use of polydioxanone plates for endoscopic skull base repair. American journal of rhinology & allergy. 2017;31(2):122-6.
Seaman SC, Moline MJ, Graham SM, Greenlee JDW. Endoscopic extrasellar skull base reconstruction using bioabsorbable plates. American journal of otolaryngology. 2021;42(1):102750.
Zhou ZY, Wang XS, Gong Y, La Ali Musyafar O, Yu JJ, Huo G, et al. Treatment with endoscopic transnasal resection of hypothalamic pilocytic astrocytomas: a single-center experience. BMC surgery. 2021;21(1):103.
Zhou Y, Hei Y, Soto JM, Jin T, Jiang X, Feng D, et al. Clinical Efficacy of the Multilayered Skull Base Reconstruction Using In Situ Bone Flap in Endoscopic Endonasal Approach for Craniopharyngioma. Journal of neurological surgery Part B, Skull base. 2022;83(Suppl 2):e291-e7.
Gruss CL, Al Komser M, Aghi MK, Pletcher SD, Goldberg AN, McDermott M, et al. Risk factors for cerebrospinal leak after endoscopic skull base reconstruction with nasoseptal flap. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2014;151(3):516-21.
Kim JS, Hong SD. Risk factors for postoperative CSF leakage after endonasal endoscopic skull base surgery: a meta-analysis and systematic review. Rhinology. 2021;59(1):10-20.

No competing interests reported.

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Utilizing In-Situ Bone Flap for Skull Base Reconstruction in Endoscopic Surgery of Invasive Pituitary Adenoma: A Novel Approach

Status:

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Abstract

Figures

Introduction

Method

Results

Conclusion

Discussion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

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