Abstract
Objective:
The optimal management paradigm for craniopharyngiomas involves gross total resection when safe or cytoreductive surgery followed by adjuvant radiotherapy if necessary. Various surgical approaches have been employed for resection of these lesions, with traditional operative techniques including open transcranial and transsphenoidal microscopic methods. The endoscopic endonasal approach represents a minimal access, maximally aggressive alternative that may be preferable in a subgroup of patients.
Methods:
We performed a MEDLINE search of the modern literature (for years 1995–2010) to identify relevant studies. Comparisons were made between open transcranial, transsphenoidal microscopic, and endonasal endoscopic series for patient and tumor characteristics as well as extent of resection, morbidity, and visual outcome. Statistical analyses of categorical variables were undertaken using chi-square and Fisher's exact tests.
Results:
Eighty-eight studies, involving 3470 patients, were included. Compared with the open transcranial cohort, the endoscopic endonasal cohort had a significantly higher percentage of gross total resection (66.9% vs. 48.3%;
P
< 0.001), higher rate of improved visual outcome (56.2% vs. 33.1%;
P
< 0.001), and a trend toward fewer recurrences (18.4% vs. 28.2%;
P
= 0.062). The transsphenoidal microscopic cohort had similar outcomes to the endoscopic group. The rate of CSF leak was higher in the endonasal endoscopic (18.4%) and transsphenoidal microscopic groups (9.0%) than in the transcranial group (2.6%) (
P
< 0.001), but the transcranial group had a higher rate of seizure (8.5%) and wound infection (2.2%), neither of which occurred in the endonasal endoscopic (
P
< 0.001 and
P
= 0.046, respectively) or transsphenoidal microscopic groups (
P
< 0.001 and
P
= 0.004, respectively). Likewise, visual deterioration was higher (11.3%) in the transcranial group (
P
= 0.23).
Conclusion:
Our systematic meta-analysis supports the endoscopic endonasal approach as a safe and effective alternative for the treatment of certain craniopharyngiomas with certain advantages over transcranial surgery in selected patient populations. Careful patient selection and meticulous multilayer closure are critical to obtaining maximal resection and minimal CSF leak rates.