Pituitary Surgery

Tumours vary in size and activity. If surgery is recommended it may be for one of three reasons:

• to remove hormone-producing tissue (typically in Acromegaly or Cushing's disease)
• to reduce the volume of a tumour that is compressing the optic chiasm or other structures
• to reduce the volume of, or excise, non hormone-producing tissue that is likely to threaten surrounding structures in the future; for example, in a relatively young patient, in whom continued growth of the tumour is suspected or has been proven by sequential scans.

Transsphenoidal surgery is the most usual method but sometimes transcranial surgery is required in some tumours with major intracranial extension. The transsphenoidal approach allows the surgeon a clear, direct view of the tumour (through an operating microscope) and avoids a craniotomy (making a hole in the skull) with its associated risks of damage to the brain and epilepsy.

Recently an endoscopic approach has been introduced in some centres.  Fine tubes (endoscopes) are pushed through the back of the nose.

MRI and/or CT scans will give the surgeon information on the size and position of the tumour.

Successful outcome of this surgery is very dependent on the experience of the surgeon.

Patient management

Prior to Surgery

The Pituitary Foundation recommends that the initial point of referral is to an Endocrinologist who will arrange for essential preliminary tests (including blood tests, MRI and visual fields) to be performed before surgery.

Follow-up

The patient will be referred to an endocrinologist for post-operative pituitary function assessment at about 5-8 weeks and back to the surgeon at about 12 weeks (for MRI and visual field assessment). In some cases additional replacement pituitary hormones will be needed.  These appointments should, ideally, be combined to cause minimal inconvenience to the patient.

Diabetes Insipidus (factsheet 8)

If the patient suffers from new onset polyuria and nocturia after surgery, it is likely that they have developed a degree of diabetes insipidus (DI). This is unusual after transsphenoidal surgery, but in all cases is highly amenable to treatment.  In most cases, DI is temporary and disappears within a few months, but in 1-2% of patients, especially after removal of Prolactinoma and Cushing's tumours, it may be permanent and remain treatable.

Cerebrospinal fluid leak

It is possible to develop a CSF leak from the nose in the post-operative period (this is rare). This is associated with a risk of meningitis, and is an inconvience for the patient.  Any flu-like symptoms or discharge of water-like fluid from the nose should be treated with a view to this posibility.  Patients need to be referred back to the surgeon for treatment urgently. 

Sinusitis

This is not uncommon after this operation, particularly for patients with acromegaly. Symptoms usually clear given time, but occasionally need further treatment or an ENT referral.

Stitches

Depending on the surgical technique, stitches are inserted in the upper gum or in the nostril.  They are usually soluble. The wound itself will be completely healed in 3 weeks. Complete absorption of stitches can take 3 months and loose ends may need to be removed/snipped away. There may be some numbness around the front teeth; this may occasionally be permanent.

Weight gain

A major problem for many patients is weight gain. These patients are likely to need some encouragement to follow a suitable diet and take regular exercise. This may be particularly difficult after a period of illness and hospitalisation. However, including more exercise into their lifestyle should also improve the patient's general feeling of well-being.

Emotional impact

Surgical treatment which involves the head has a strong emotional impact for some patients.  Please see 'Psychological Issues' (factsheet 13).

Resources for patients

Please go to the Resource Library of this website to access resources for patients.  Our library includes literuature, newsletters and articles available from The Pituitary Foundation as well as the contact information for other organisations who provide support and information.  All of our patient leaflets are available to read as well as downloadable in PDF format from this website. 

Resources for GPs

Endotext.org "Your Endocrine Source"
http://www.endotext.org/    (www.endotext.org/neuroendo/index.htm)