The transsphenoidal surgical technique has dominated ever since Jules Hardy introduced microsurgery with the use of an operation microscope in the 1960s. Since the 1990s, endoscopic techniques have alternatively been applied in transsphenoidal surgery. Both microscopy and endoscopy should be accepted as established techniques which can often be used in a complementary fashion. It must be understood that microsurgery and endoscopy differ only in that they use different optical systems. The surgical access selected and the neurosurgeons experience are much more decisive for the surgical outcome.
Extended transsphenoidal approaches have found their way into pituitary surgery during the past decade. This enables excision of pituitary tumours which extend well beyond the borders of the sella turcica. Using the transtuberculum sellae approach, for example, suprasellar tumours which used to be approached only via a craniotomy can be excised via a transnasal procedure.
Pituitary surgery is accepted for primary treatment in non-functioning adenomas, in acromegaly, and in Cushings disease. In recent years, pituitary surgery is experiencing a renaissance in the treatment of prolactinomas. Surgical remission rates >90% with minimal surgical risk have been demonstrated for microadenomas. For this reason, surgical treatment is regaining acceptance as an alternative to often life-long dopamine-agonist therapy of prolactinomas.
Neuronavigation is widespread these days as a modern technology for intraoperative orientation. In pituitary surgery, it is preferentially used in difficult recurrence operations, in carotid artery narrowing or encasement by tumour, and in children with non-pneumatized sphenoid bone. Intraoperative magnetic resonance imaging (MRI) enables a valid control of the resection result and, if necessary, further resection during the same surgical intervention. Intraoperative MRI is, however, available in only a few large centers.
Over 90% of pituitary tumours can be excised these days via classical or extended transnasal approaches. The use of modern intraoperative technologies increases the safety and radicality of tumour removal.