Pituitary tumor surgery performed via a transsphenoidal approach is a specialized neurosurgical procedure aimed at resecting abnormal growths on the pituitary gland—the master gland that regulates systemic hormone distribution. By entering through the nostrils (endonasal) and traversing the sphenoid sinus (an air-filled cavity behind the nose), surgeons reach the sella turcica (the bony saddle-shaped structure containing the pituitary gland). The primary goals of this procedure are relieving neurological pressure on nearby optic pathways and normalizing pituitary hormone secretion. It falls within the domains of neurosurgery and skull-base surgical oncology.

The patient is positioned supine under general anesthesia with image-guided neuronavigation calibrated to preoperative MRI/CT scans. An otolaryngologist or neurosurgeon introduces a rigid endoscope or surgical microscope through the nostril. The nasal mucosa is decongested, and the sphenoid ostium is identified. The anterior wall of the sphenoid sinus is opened, and the sphenoid septum is removed to expose the sellar floor. Using fine instruments, the surgeon creates a opening in the thin sellar bone and opens the underlying dura mater. The pituitary tumor is systematically resected using curettes, suction, and micro-scissors while preserving normal pituitary tissue. Once resection is complete, the surgical site is inspected for bleeding and CSF leaks. Reconstruction of the sellar floor is performed using autologous fat, fascia, bone grafts, synthetic sealant, or a vascularized nasoseptal flap as required. Nasal packing or soft splints may be placed before extubation.

Transsphenoidal pituitary tumor surgery provides documented clinical benefits over traditional transcranial craniotomy (open brain surgery) and non-surgical management when indicated:

• Minimally Invasive Access: Eliminates external facial or cranial incisions, avoiding brain retraction and reducing operative tissue trauma.
• Rapid Visual Decompression: Immediate mechanical decompression of the optic chiasm typically leads to rapid improvement in visual acuity and visual field deficits (Zada et al., 2019).
• High Rates of Biochemical Remission: Provides immediate endocrine cure or control for hormone-secreting adenomas, such as Cushing's disease and acromegaly, when complete resection is achieved (Giustina et al., 2020).
• Tissue Diagnosis: Obtains direct tissue specimens for precise histological, immunohistochemical, and molecular profiling.
• Shorter Hospitalization: Reduces inpatient stay to an average of one to three days, lowering infection risk and accelerating return to functional activities.

Recovery following transsphenoidal surgery occurs in distinct phases across six to twelve weeks. In the immediate postoperative period (Days 1–3), patients remain hospitalized to monitor neurological status, nasal drainage, and fluid homeostasis. Fluid monitoring is crucial to detect diabetes insipidus (a transient disorder of water balance causing excessive urination) or SIADH (syndrome of inappropriate antidiuretic hormone secretion causing low blood sodium).

During Weeks 1 to 2 at home, patients experience mild nasal congestion, fatigue, and occasional headaches. Physical activity is limited; patients must strictly avoid nose blowing, coughing vigorously, sneezing with a closed mouth, straining during bowel movements, or bending forward at the waist to prevent a cerebrospinal fluid (CSF) leak (clear brain fluid leaking through the nose). During Weeks 3 to 6, energy levels improve, and soft tissue within the sphenoid sinus heals. Follow-up visits with neurosurgery, otolaryngology, and endocrinology evaluate nasal mucosal healing, baseline morning cortisol levels, and hormonal status. Endocrine reassessment and dynamic testing occur at 6 to 12 weeks post-surgery, with surveillance MRI performed at 3 to 6 months to evaluate tumor resection extent.

Transsphenoidal pituitary tumor surgery is indicated for a range of benign and select aggressive tumors located in and around the sella turcica. Conditions treated include:

• Non-functioning pituitary adenomas: Tumors that do not produce excess hormones but cause mass effect on the optic chiasm.
• ACTH-secreting adenomas: Tumors driving Cushing's disease through excessive adrenocorticotropic hormone production.
• GH-secreting adenomas: Tumors producing excess growth hormone, resulting in acromegaly.
• TSH-secreting adenomas: Rare tumors causing secondary hyperthyroidism.
• Prolactinomas refractory to medical therapy: Prolactin-secreting tumors that fail to respond to, or cannot tolerate, dopamine agonist medications.
• Rathke cleft cysts and craniopharyngiomas: Non-adenomatous benign cystic lesions of the sellar region.
• Pituitary apoplexy: Sudden hemorrhage or infarction into a pituitary tumor requiring emergency decompression.

Preoperative preparation requires a detailed neuro-ophthalmological visual field evaluation, dedicated high-resolution pituitary MRI, and a comprehensive endocrine panel measuring prolactin, cortisol, ACTH, GH, IGF-1, TSH, free T4, LH, FSH, and testosterone/estrogen. Patients undergo nasal endoscopic examination by an otolaryngologist to assess airway geometry and rule out active sinus infections. Anticoagulants, antiplatelets, and nonsteroidal anti-inflammatory drugs (NSAIDs) are discontinued 7 to 14 days prior to surgery based on surgical team instructions. Patients receive perioperative stress-dose glucocorticoids if baseline morning cortisol levels indicate adrenal insufficiency or to protect against surgical stress.

Complications are stratified by severity. Mild to moderate common effects include transient nasal congestion, sinus pressure, altered sense of smell (anosmia or hyposmia), minor epistaxis (nosebleeds), and transient diabetes insipidus. Moderate complications include permanent hypopituitarism requiring lifelong hormone replacement therapy, persistent diabetes insipidus, postoperative CSF leak requiring lumbar drainage or surgical repair, and local sinus infections. Rare but serious risks include severe arterial injury to the internal carotid artery, intraoperative or postoperative intracranial hemorrhage, visual loss secondary to optic nerve damage, meningitis, and deep vein thrombosis or pulmonary embolism.

The clinical journey begins with an extensive diagnostic evaluation, including high-resolution magnetic resonance imaging (MRI), baseline endocrine blood panels, and formal visual field testing. Preoperative preparation involves nasal passage clearing, steroid dosing adjustments, and surgical planning using image guidance. On the day of surgery, general anesthesia is administered, and the surgical team removes the tumor using either endoscopic or microscopic instruments. Following resection, the sellar floor is reconstructed to prevent fluid leakage. Postoperatively, patients spend 24 to 48 hours in the hospital under close monitoring for fluid and electrolyte changes, specifically urine output and blood sodium. Full home recovery spans two to six weeks, followed by dynamic hormone testing and surveillance imaging at designated intervals.