Endoscopic transsphenoidal pituitary surgery

Endoscopic transsphenoidal pituitary surgery is an operation through the nose most used to remove a tumour of the pituitary gland. “Endoscopic” means use of a camera, and “transsphenoidal” means through the sphenoid sinus, the air sinus (cavity) at the back of your nose.

The indications of this operation include:

Removing a pituitary tumour such as an adenoma, Rathke’s cleft cyst, craniopharyngioma, and meningioma.

It can also be done to decompress the optic nerve or repair the base of the skull.

The pituitary is a gland about the size of a pea and is located at the base of the brain behind your eyes. The pituitary gland produces chemical messengers called hormones, which control important body functions.

These include:

• Response to stress
• Metabolic rate (the speed at which your body functions)
• Growth
• Milk production
• Sexual function and fertility
• The balance of water in the body.

The pituitary gland is located near the nerves that carry information from the eyes to the brain (optic nerves). Tumours of the pituitary gland can cause difficulty with vision, such as tunnel vision, blurred vision, or double vision. They can also cause changes to body functions and even your appearance depending on whether any of your hormones are affected.

A transsphenoidal operation is intended to improve or protect your eyesight and, in some situations, to correct the over-production of hormones.

All operations and procedures have risks, and we will talk to you about the risks of transsphenoidal surgery. This procedure is performed under general anaesthetic, which means you will be unconscious and unaware or ‘asleep’ throughout. Your anaesthetist will talk to you about the risks of general anaesthesia. They will talk to you about pain control and prescribe pain-relieving medicines.

Problems that may happen straight away

• Pain: Sore nose and headache. This happens quite commonly, and you will be given pain killers regularly and as required.
• Nausea and vomiting: This can be caused by blood trickling into the stomach during or following surgery. We prescribe medicines to counteract this.

Problems that may happen later

• Cerebrospinal Fluid (CSF) leak: CSF is clear fluid which surrounds the brain and spinal cord. CSF leaks occurring during surgery are sealed using special surgical glue or a small piece of fat taken from the abdomen or thigh. Occasionally leaks during surgery may require the insertion of a lumbar drain to help seal the leak. A lumbar drain is a thin plastic tube connected to a drainage bag. It is inserted into the CSF space around the spine in the lower back. Most drains are required for about 3 days. About 5 in every 100 patients will require treatment of a CSF leak following surgery which may entail either further fat or a lumbar drain. Sometimes a drain is planned to be inserted before the operation. You will be informed if this is the case.
• Diabetes Insipidus: This is a condition where the hormone that regulates water balance (Vasopressin) in the body is affected. Diabetes insipidus causes people to feel very thirsty and to pass large amounts of urine. It often settles down after a few days. It can be treated with hormone replacement.
• Hypopituitarism: The pituitary gland can be damaged by the tumour, and this is sometimes worsened by surgery. In this case, medication is required to replace the natural hormones that keep the body healthy. These may include hydrocortisone, levothyroxine, oestrogen/ testosterone and occasionally growth hormone. About one in ten patients will require additional hormone replacement after surgery.

Problems that are rare, but serious

• Worsening of vision. This happens rarely but is more common in patients who have significant problems with their eyesight before surgery. Very occasionally, another operation is required to remove a small blood clot causing pressure on the nerves to the eyes.
• Injury to the carotid arteries. These lie on either side of the pituitary gland and supply blood to the brain. Injury to the carotid arteries during surgery may lead to serious complications such as stroke or death. There is a very small chance of this, much less than one in a hundred patients.

Sometimes it is not possible to remove all or enough of the tumour and you may find that your symptoms are the same or that your eyesight has not improved. In this case, further treatment may be required, including medications, a larger operation through the brain (craniotomy) and/or radiotherapy.

The choice to go ahead with surgery is entirely yours. If you choose not to have this surgery, your vision may worsen, in some situations leading to blindness. Other systems in your body may be damaged by the effects of too much or too little of the hormones, such as your heart or the effects of diabetes or high blood pressure. It may also be more difficult to treat your tumour later if you delay surgery.

If you decide not to go ahead with surgery, you will continue to be under our care, and we will support you in your decision.

Your neurosurgeon will talk to you about all alternative treatments and their risks and benefits.

Medications: Some pituitary tumours can be treated with medication under the care of an endocrinologist (a doctor who specialises in hormone disorders). However, this treatment is not suitable for most pituitary tumours.

Radiotherapy: X-ray treatment can be used to control the growth of some tumours. Often used as adjunctive treatment after surgery.

Gamma knife surgery: Also known as stereotactic radiosurgery, is a form of radiotherapy which involves directing several beams of radiation at the tumour. It is only suitable for some small tumours.

You may be seen in the Pre-operative Assessment Clinic a few weeks before your admission to hospital for surgery. Any tests which may be necessary can be done at this appointment. You will be seen by a doctor and nurse and will have the opportunity to ask any questions you may have.

They will ask you about all medicines you are taking and advise you about which if any medicines need to be stopped prior to surgery. They will also tell you when to fast from if you are to be admitted on the day of surgery.

It is advised that you improve your general health prior to surgery by doing things such as eating a healthy diet, stop smoking and doing gentle exercise.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves.

Staff will explain all the risks, benefits, and alternatives before they ask you to sign a consent form. You may also be asked whether you wish to be involved in ongoing research projects on pituitary disease.

This is entirely your decision and will not impact your clinical care. If you are unsure about any aspect of your proposed treatment, or of the proposed research, please do not hesitate to speak with a senior member of staff again.

You will be admitted on the day of surgery or the night before if you require to have another MRI scan to be used during the operation or you are travelling from very far away.

The nurse looking after you or a member of staff from the admissions lounge will escort you to the operating theatre. They will give you a gown and some elastic stockings to wear.

Operating theatre staff will confirm your identity and the operation you are having.

The anaesthetic is commenced in an anaesthetic room next to the operating theatre. Once you are ‘asleep’ you will be moved to the theatre and carefully positioned on the operating table.

The pituitary gland is reached through your nose. The surgeon will use an endoscope to perform the procedure.

Often the surgeon will also take a small piece of fat from your abdomen called a fat graft used to repair the surgical area. Occasionally a lumbar drain will also be placed.

The operation takes approximately one to two hours. Afterwards you will stay in the recovery ward until you are fully awake and well enough to go back to a ward.

You will have a light plastic mask over your nose to give you oxygen and this will stay in place until the evening or following morning. A nose ‘pack’ is often inserted in one or both nostrils with a gauze dressing under your nose. You will need to breathe through your mouth so you may feel quite dry.

We will monitor your pulse, blood pressure and oxygen levels regularly. We also need to record how much fluid you drink and how much urine you pass.

You will have a drip to keep you hydrated until you can drink enough, usually the next morning. You may start to eat and drink as soon as you feel able. If you feel sick, we can give you medication to help.

A nurse or nursing assistant will help you to get up and about until you feel steady enough to walk on your own. We expect you to be walking about on your own by the day after the operation. You will often also receive injections to thin the blood. This helps to avoid complications such as deep vein thrombosis (blood clots in your leg veins) and chest infection.

You will need to have blood tests over the next few days.

You may have a nose pack left in after surgery which is then removed three to five days after surgery.

There will be some leakage of blood-stained mucous from your nose for a few days afterwards. Your nurse will put a gauze pad under your nose to catch any leakage.

Please tell your nurse or doctor immediately if you notice leakage of thin, clear, watery fluid from your nose or a trickle of salty tasting fluid down your throat. This may mean a CSF leak has developed, for which you are likely to require further treatment (usually a lumbar drain).

Your nose will feel blocked so you will breathe through your mouth. You can use mouthwashes or water to keep your mouth moist.

Do not stick anything up your nose, even to clean it. Do Not Blow your nose. Avoid sniffing, bending forwards or lifting heavy weights for four to six weeks after surgery. This is to help the wound at the top of your nose to heal thoroughly.

Do not swim with your head under the water until you have seen your doctor in the outpatient clinic.

If you had a fat graft taken during surgery, you will have a small wound and dressing on your abdomen or sometimes your thigh. The wound is usually closed with clips which will need to be removed a week after the operation.

The nurse caring for you on the ward will tell you how to look after your wound and give you a letter to take to your GP if necessary.

You should expect to be in hospital for two to three days. You will be discharged once you are feeling well enough to go home. Sometimes you will need to stay for a longer period until the blood tests are completely normal or until you feel well enough. 

You may want to have another person accompany you when you are admitted to the hospital. After the operation you may also have friends and family come to see you during the ward visiting hours.

Criteria that need to be met prior to discharge: 

• You are able to walk independently and manage to go to the bathroom by yourself.
• You blood tests: sodium, renal function and blood sugars are within normal levels.
• Steroid plan in place (see Steroid medication).
• Follow up plan with endocrinology and neurosurgery in place.
• Pain under control.
• No nasal fluid leak.

The thirst mechanism can be affected by transsphenoidal surgery.

After your discharge it is advised to keep a record of the amount you are drinking and the amount of urine that you are passing. You may be provided with a fluid balance sheet on discharge. This is only required for the first 7 days after surgery.

It is advised that you aim to drink 1.5 to 2 Litres of fluid daily for the first week. If you find that you need to drink more than this because of severe thirst, please contact the pituitary nurse specialist on 07538 206413.

Some patients will require hormone replacement therapy after surgery. The most important hormone is called cortisol. Cortisol is a type of steroid, which helps your body to cope with stress. The drug most used to replace cortisol is called hydrocortisone.

If you are prescribed hydrocortisone tablets, please read the information leaflet provided with your medicines carefully. You must take the tablets as directed by your doctor. If you take hydrocortisone late in the day, you may find that you have difficulty sleeping.

Do not miss out any doses unless your doctor has advised you to do so, such as before certain blood tests.

Ensure you do not run out of tablets and always go to your GP for a new supply in plenty of time.

You will be given a ‘steroid card’ to always carry with you. If you have an accident, a sudden illness, an operation, or dental treatment it is important that the doctors treating you know that you are taking steroid medication.

There is a specific patient information sheet regarding hydrocortisone medication. If you do not already have one, please ask the pituitary clinical specialist nurse or your treating doctor for a copy.

If you have any of the following, please contact the Pituitary Team immediately during working hours on 07538 206413:

• Leak of clear, watery fluid dripping from your nose
• Heavy fresh bleeding from your nose that cannot be easily stopped
• Severe thirst
• Passing large amounts of urine
• Unable to take your hydrocortisone, e.g., you have vomiting or diarrhoea 
• Headaches not relieved by simple painkillers
• Fever
• Drowsiness
• Feeling generally unwell or excessively tired a week or two after surgery.

Outside of normal working hours, if your problem is urgent, contact your on-call GP or go to the accident and emergency department at your local hospital.

Alternatively, urgent advice can be sought from the on-call neurosurgical doctor via the hospital switchboard on 020 3456 7890, bleep 8100.

General advice following trans-sphenoidal surgery:

• Drink to thirst – but aim around 1.5-2 litres (see above). 
• Nose care – Try to sneeze with mouth open if possible. Do not blow your nose for 6 weeks. If troublesome nasal congestion, can do steam inhalation for 3-5 minutes, twice daily.
• You may experience changes to your sense of smell. Omega 3 supplements for 4-6 weeks may help to recover it.
• Headaches that improve with standard painkillers and/or a rest are not concerning in nature.
• Avoid straining (take laxatives if necessary)
• Avoid lifting heavy weight for 6 weeks.
• Following pituitary surgery people experience tiredness that can last for 6-8 weeks. We advise to adopt a gentle lifestyle for this length of time.
• Encouraged to do daily walks to prevent possible complications related to general anaesthetic such as blood clots and chest infections.
• Fat graft wound – keep dry until clips are removed. Please make an appointment with your GP a week after discharged.
• If your vision has been affected by the pituitary tumour, please notify the DVLA as soon as possible. You must not to drive until advice otherwise by DVLA.
• We advise to wait for 2-3 months before changing prescription glasses as vision can continue to improve for the next couple of months.
• We advise to take 6-8 weeks off work. You should use a phased return to work at the appropriate time.

You need to be seen by a member of the team in the outpatient clinic approximately a week after surgery and again six to eight weeks after your operation. If you are not given the details of this appointment before you leave the hospital, it will be sent to you by post. You may have blood tests at this follow up appointment.

Any other investigations, such as eye tests or a head scan are usually arranged following this visit. Typically, an MRI is requested after four months, and a follow up appointment arranged after six months.

Depending on where you live, you may be referred to your local endocrinologist for long term follow up.

The Pituitary Foundation

P.O. Box 1944 Bristol

BS99 2UB

Telephone/fax: 0845 450 0376

Email: helpline@pituitaryorg.uk

Website: www.pituitary.org.uk

National Institute for Health and Clinical Excellence

Website: www.nice.org.uk

UCLH Patient Medicine Helpline

Email: infomed@uclh.nhs.uk

Telephone: 020 3447 3025

UCLH cannot accept responsibility for information provided by other organisations.

Pituitary Nurse Specialist

Direct line: 020 3448 3265

Mobile: 075 3820 6413

Email: UCLH.NHNN-PituitaryCNS@nhs.net

Neurosurgeon

Secretary: 020 3448 3305 / 3421 uclh.neurosurgery.admin@nhs.net

Endocrinologist

Secretary: 07966 770637 uclh.endo@nhs.net

UCLH Switchboard: 0845 155 5000 (There is no additional charge for using an 0845 number. The cost is determined by your phone company’s access charge)

Address:

Box 116, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG

Website:

www.uclh.nhs.uk

www.ucl.ac.uk/ion-skull-base-unit