Application of the Three Points and Three Lines Method to Accurately Open the Sellar Floor in Microscopic Transsphenoidal Surgery of Pituitary Adenomas

Abstract

Objective: In this study, the sellar floor morphology of patients with pituitary adenoma is analyzed and a simple yet reliable method is identified to determine the location of bone window opening.

Methods: Clinical information of 144 consecutively admitted patients was retrospectively analyzed. Enhanced magnetic resonance imaging of the midsagittal plane was selected as the reference for classifying the sellar floor. Intraoperative tumor location, extent of tumor resection, and follow-up results were analyzed for different types of sellar floor. The tuberculum sellae, lowest point of the sphenoid sinus, and the lowest point of the sellar floor and 3 lines related to them were used to classify the sellar floor. This is referred to as the "three points and three lines" method.

Results: Based on its location in the sphenoid sinus, the sellar floor can be classified into 4 types: 12 patients (8.3%) with high sellar, 70 (48.6%) with medium sellar, 30 (20.8%) with low sellar, and 32 (22.8%) with steep sellar. The maximum tumor diameter, maximum sellar floor diameter, and the intercarotid distance were all significantly different among patients with different types of sellar floor (P < 0.001). For all patients, quick intraoperative location of the sellar floor opening was achieved. A total of 104 patients (72.2%) had total tumor resection, 28 (19.40%) had subtotal tumor resection, and 4 (2.8%) had partial tumor resection. Twenty patients (13.9%) experienced cerebrospinal fluid leak, and there was no significant difference in cerebrospinal fluid leak rate among groups.

Conclusions: Presurgical classification and location of the sellar floor are critical for understanding and assessing the transsphenoidal approach. Different types of sellar floor appeared in the surgery with different morphologic features. The three points and three lines method helps the surgeon to predetermine the location of the sellar floor opening and to shorten surgical time.

Keywords: CSF leak; Microscopic transsphenoidal surgery; Pituitary adenomas; Sellar floor; Three points and three lines method.