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Pituitary Surgery

Pituitary surgery is an operation in which tumors on or near the pituitary gland are removed. The pituitary is a pea-sized gland at the base of the brain, approximately three inches behind the bridge of the nose. It secretes multiple hormones, which control systems throughout the body. Pituitary surgery can be performed with a few approaches, most of which involve no visible incisions.

A neurosurgeon’s choice of approach largely depends on a tumor’s location in the brain. In the case of pituitary tumors, some grow down into the sphenoid sinus, which is part of the nasal cavity. A neurosurgeon can, therefore, access and remove these tumors by operating through either the top of the skull, or through the nose.

The most common approach is operating through the sphenoid sinus in the nose, an approach called transsphenoidal surgery. To perform transsphenoidal surgery, a neurosurgeon travels through the nostril or the gums, without any incision in the skin. This is often referred to as endoscopic transsphenoidal surgery or endoscopic endonasal surgery. This is performed with an endoscope, a thin, flexible device equipped with a tiny camera and light on the tip that can be passed through the nostrils and navigated to the sphenoid sinus. With the aid of an endoscope, incisions inside the mouth are unnecessary.

If the tumor is particularly large or infiltrating deep into the brain, a neurosurgeon may choose instead to operate through the skull by performing a craniotomy. In this procedure, a neurosurgeon makes an incision on the scalp and then removes part of the skull to gain access to the brain.

When is this procedure performed?

Pituitary tumors are relatively common tumors and comprise about 10 to 15 percent of brain tumors. A portion of people with pituitary tumors have asymptomatic disease and live their whole lives without ever noticing the tumor. Even when the tumor is picked up on imaging, surgery may not be necessary.

However, pituitary tumors that do produce symptoms tend to interfere with a person’s quality of life, and therefore they need treatment. These tumors can affect hormone levels, leading to a variety of health conditions, and can also damage nearby structures-in particular the optic nerve, necessary for vision.

The first step of treatment is typically surgical tumor resection, the goal of which is complete resection. When only subtotal resection can be safely achieved, additional therapeutic options are available for the residual tumor. The main exceptions to this general rule are prolactinomas, which can often be treated with long-term medication instead of surgery.

How is this procedure performed?

Both transsphenoidal surgery and a craniotomy start with general anesthesia, which is used so that patients do not feel pain during the procedure. From there, the procedures vary:

Transsphenoidal surgery:
This minimally invasive procedure begins with inserting the tip of an endoscope through one of the nostrils and then opening up the sphenoid sinus at the back of the nasal cavity. An endoscope or microscope provides light and magnification so the surgeon has a clear view of the surgical field deep inside the nose. Instruments are passed through the nose to reach the tumor.

Upon reaching the pituitary tumor, the neurosurgeon uses instruments to delicately dissect the tumor away from the pituitary gland and any other structures, like the optic nerve, to which it may be attached. The neurosurgeon is able to achieve the highest precision by using advanced computer technology and imaging tools, like magnetic resonance imaging (MRI) and computed tomography (CT) scans, to produce a 3-dimensional map of these and other structures in a patient’s brain.

Next, the neurosurgeon uses high-tech instruments to carefully break up and aspirate pieces of the pituitary tumor. As much of the tumor is removed as possible while preserving the pituitary gland and other brain tissue and structures. During tumor resection, the neurosurgeon also biopsies the tumor and sends it to a pathologist to confirm a diagnosis.

After tumor resection, the neurosurgeon may need to fill the space the tumor had previously occupied. If so, the neurosurgeon occasionally obtains a tissue graft from the patient’s abdomen or thigh and implants it where the tumor had been. Often, synthetic grafts and biologic glue can be used instead of making an incision in the abdomen or thigh. If incisions were made, those are stitched. Then the surgery is complete.

Craniotomy:
The other surgical method involves operating through the skull instead of the nasal cavity.

The neurosurgeon starts by making an incision on the front or side of the head and then pulls back the skin and muscle to expose the skull bone. Next, the neurosurgeon removes a small piece of the skull bone, exposing the dura mater, and the skull piece is saved so that it can be replaced later. Using surgical scissors, the neurosurgeon carefully cuts through the dura mater. Because the skull has minimal extra space and the brain tissue, blood vessels and nerves are fragile, the neurosurgeon uses an operating microscope and other advanced technology to navigate through the available space and reach the pituitary tumor.

Because of advances in technology, the neurosurgeon also uses stereotactic techniques, which employ computer technology and imaging tools like MRI and CT scan to produce 3-dimensional images of the brain. The neurosurgeon uses these images to precisely navigate to the tumor and avoid harming healthy brain tissue.

Upon reaching the pituitary tumor, the neurosurgeon begins meticulously dissecting the tumor away from the pituitary gland and other important structures like the optic nerve. The neurosurgeon is careful to resect as much of the tumor as possible without damaging normal tissue. A biopsy of the excised tumor is taken and sent to a pathologist for analysis in order to confirm a diagnosis.

Once as much tumor as possible is removed, the neurosurgeon stitches up the incision in the dura mater and then replaces the piece of skull bone, which is secured with titanium plates and screws. Lastly, the neurosurgeon stitches up the incision on the scalp. The surgery is then finished.

How should I prepare for this procedure?

Tell your doctor about any medications or supplements, including herbs or vitamins, you are taking. It is important for your doctor to know because you will likely be asked to not take certain medicines or supplements that can increase bleeding during surgery, like aspirin and warfarin. Also, make your doctor aware of any allergies you have to medications or food.

Because general anesthesia is used during surgery, your doctor will ask that you stop eating and drinking at midnight the night before the procedure. If your doctor has instructed that you continue taking certain medications the day of surgery, do so with a small sip of water.

On the day of surgery, wear loose, comfortable clothing. Do not wear makeup, jewelry, body piercings or contact lenses; instead wear your glasses.

For your overnight or weeklong stay, be sure to pack lightly. A few common items that patients like to bring include toiletries, dentures and a change of clothing for when they are discharged from the hospital.

Be sure to arrange transportation home because you will not be allowed to drive yourself home after surgery.

What can I expect after the procedure?

How long will I stay in the hospital?
Typically, patients who undergo transsphenoidal surgery, which is the most common operation, stay in the hospital for one or two days and then are discharged to go home. Those who undergo craniotomy stay longer, around one week.

Will I need to take any special medications?
Patients who receive transsphenoidal surgery are prescribed medication for pain and sometimes nausea, and those who receive craniotomy may take additional medications, including those to prevent seizure, brain swelling and stomach ulcers.

Also, patients with low levels of one or more pituitary hormones may receive hormone replacement therapy, which will likely be prescribed long-term.

When can I resume exercise?
Patients who undergo transsphenoidal surgery can expect to resume light exercise, such as jogging or swimming, about two weeks after surgery, and regular exercise after about four weeks. Patients are typically walking the day after surgery but may notice that they tire very easily and need to rest often. This level of fatigue is normal.

Patients who undergo craniotomy will need to recover longer before returning to their regular exercise routine, and when they do, they should exercise with a partner or under supervision until fully recovered. Patients can only begin light exercise and eventually more strenuous exercise once the neurosurgeon approves that level of activity. It’s recommended to get up and take a walk every day if patients have the energy.

What follow-up will I receive?
Patients will be scheduled for several follow-up appointments with their neurosurgeon and endocrinologist. Patients who had vision problems before surgery or now have vision problems will also have an appointment with their ophthalmologist.

During these appointments, the neurosurgeon will check how well the patient is recovering and will order an MRI to check for residual tumor. If residual tumor is detected, a patient’s neurosurgeon may suggest radiation therapy to eliminate it. The endocrinologist will order blood tests to check hormone levels and prescribe medications for hormone replacement therapy if the pituitary gland is not producing enough of a particular hormone. The ophthalmologist will assess a patient’s vision.

It is important for patients to attend all of these appointments in order to have the best possible recovery. Also, patients should tell their doctor about any new or worsening symptoms.

Will I need rehabilitation or physical therapy?
Patients typically do not need physical therapy.

Will I have any long-term limitations due to pituitary surgery?
Patients who had a particularly large or aggressive pituitary tumor removed may have reduced brain function or a shorter lifespan, but those outcomes are very rare. The reason for these long-term effects is either the tumor damaged nearby brain tissue or tissue was damaged during surgery. Our highly experienced neurosurgeons at Columbia are very careful to avoid any harm during surgery.

Frequently, patients can have diabetes insipidus for a few days after surgery, the symptoms of which are feeling very thirsty or having to urinate frequently. This condition occurs when too little antidiuretic hormone is secreted from the pituitary gland. Antidiuretic hormone instructs the kidneys to limit the amount of water in the urine- so without this hormone, the kidneys release too much water. Most often, patients are instructed to drink plenty of water and diabetes insipidus resolves after a few days. However, rarely, diabetes insipidus can persist, even throughout a person’s life, and for these patients, hormone replacement therapy is needed to replace the diminished levels of antidiuretic hormone.

Preparing for your appointment

At Columbia University Medical Center/NewYork-Presbyterian Hospital, Dr. Richard  Anderson (Pediatric), Dr. Jeffrey Bruce, Dr. Neil Feldstein (Pediatric) and Dr. Marc Otten are experts in pituitary surgery. Each can also offer you a second opinion.

patient journey

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