Pituitary Tumours

Mr Law performs Endoscopic trans-sphenoidal surgery on 30 to 50 patients per year with tumours of the pituitary gland. Surgery through the nose provides access to an air sinus that lies directly underneath the tumour. The tumour is then removed in fragments using the operating microscope for magnification and lighting.

Surgery is frequently performed in conjunction with Mr Michael Davison, an Otorhinolaryngologist, who is an expert nasal endoscopist and performs the nasal dissection component of the operation.

Pituitary Surgery

The pituitary gland is situated at the base of your brain. It is attached by a stalk and sits in a depression in the skull called the pituitary fossa. This gland produces chemicals that are required for the everyday health of your body and its systems. Tumours can develop in the gland and fall into two main groups : Functioning, where they produce an excess of hormones, or Non functioning, where the tumours tend to grow large, squash the normal pituitary gland and lead to deficiency of hormones or press on the eye nerves causing visual field loss. Most tumours are benign and slow growing.

Surgery to debulk or reduce the mass of the tumour is usually carried out through the nose. In very large tumours, the operation may be performed through the skull via a craniotomy. An endoscope is used in all cases to enable excellent visualisation at surgery.

The goals of surgery

The purpose of surgery is to take away as much mass of the tumour as is possible, confirm the diagnosis histologically and prevent ongoing compression of the vital structures. A repeat MRI is performed at 3 months postop. If a significant mass of tumour remains, further surgery may be warranted or consideration may be given to radiotherapy. If there is little residual tumour, then serial 1 yearly MRI scans are performed to confirm that no further treatment is necessary. Approximately 30% of patients will require some form of additional therapy at some stage in the future.

Pre Operative Pituitary Tumour

Post Operative Pituitary Tumour

Perioperative Period

Surgery is usually performed through your nose using an Endoscopic trans-sphenoidal technique . This allows access into the air cavity at the back of your nose that lies underneath the pituitary fossa. The floor of the pituitary fossa can be opened at surgery and the tumour then reduced in size or removed.

Possible Complications

Complication are not common but do occur and it is important that you understand the seriousness of the surgery that has been proposed.

  • Hormone replacement Many patients will require replacement medication for cortisol (Hydrocortisone), thyroid hormones (Thyroxine), testosterone or ADH (Minrin). You may already be on these before surgery but if not surgery does increase the chance that you may need to take some or all of these.
  • Death / Stroke / Bleeding Because the pituitary gland sits between the 2 carotid arteries at the base of your brain, there is a chance that these can be injured at surgery. The consequence of this can be very serious.
  • CSF / spinal fluid leaks the brain is surrounded in fluid that can be released at surgery. To seal this, we often put a plug of fat into the site from where the tumour is removed. The fat is taken from an incision from around the umbilicus (belly button). We prepare all patients for this but only use if it is required.
  • Visual decline This is uncommon but a possibility when considering nerves that may have been damaged preoperatively.
  • Nasal Bleeding
  • Sinusitis
  • Headaches Most patients feel some form of headache for a few weeks after surgery. These are usually managed with simple pain relief such as panadol before going away.
  • Infection
  • Need for further surgery

After Surgery

Most people find the surgery tolerable with nasal discomfort worst on the night after surgery.

Patients come out of surgery with a urinary catheter and intravenous/arterial lines. These are monitored in a High Dependency Unit area where close assessment of blood pressure, neurological observations and urine output is possible. You are awake and communicative within minutes of surgery and relatives are welcome to visit after about an hour.

The day after surgery, you are encouraged to get up and walk around. The urinary catheter stays in place for 2 days to keep an eye on fluid balance and work out whether medication is required to treat diabetes insipidis (water diabetes).

  • Most people get discharged on the 3-4th postoperative day and go home on Hydrocortisone. I encourage a review by your Endocrinologist at 2-3 weeks after surgery to allow planning of the need for longer term medication.
  • You are encouraged to walk 15-30 minutes twice a day.
  • You should avoid heavy lifting for 4 weeks.
  • You should discuss driving with your Neurosurgeon before discharge if you have no visual abnormality pre or postoperatively, then you will be allowed to drive 1-2 weeks postop.
  • Time off work : This depends on your type of work. Generally 2-3 weeks for office work and 3-4 weeks for strenuous work.

Pituitary Surgery Discharge Instructions

(The information below can be downloaded via the link above)

Please take your usual medication and any medication prescribed for you on discharge.
Please ask if any questions or concerns

Hydrocortisone
Usual doses are 20mg morning, 10mg evening OR 10mg morning, 5mg evening
It is essential that you take this medication EVERY DAY. You must not stop this
unless instructed by your doctor
If you are unwell, develop an infection or flu – please double your usual dose until
instructed otherwise by your Doctor

Endocrinologist
It is important that you have a follow-up appointment with your Endocrinologist a
few weeks after surgery. This will allow a check on your hormone replacements and
allow your medications to be optimised.

Nasal washouts = Neil’s Sinus Rinse
Begin 5 days postop – 2 times per day (each nostril). You can reduce to once a day if
fluid clear and sinuses open. Please continue daily for at least 10 weeks.
Extra sachets can be purchased from your local Pharmacy

Fluid balance
Be careful with the volume of fluid that you drink in the first couple of weeks after
surgery. Your body frequently retains excess water leading to dilution of your body
chemicals (SIADH) – Hyponatraemia. I would suggest that you try and restrict your
daily intake to about 1 litre per day.

Daily activities
Please avoid heavy lifting or straining for a period of 6 weeks. Try and avoid
constipation – keep up fruit and vegetables with your diet. Kiwi crush (frozen
kiwifruit drink available in frozen section of supermarket) is useful. You can return
to sexual activity when you feel up to it.

Driving
If you have no visual abnormalities, you can drive a motor vehicle when you feel up
to it. If you had preoperative visual field loss, I would suggest that you arrange a
review by your Ophthalmologist / Optometrist approximately 3 weeks after surgery
to assess whether your vision is sufficient to allow you to drive.

Usual ongoing symptoms
• Low grade frontal / midface headache
• Sinus symptoms

If you

Feel unwell, nauseated, worsening headache, fever — Please see your General Practitioner or go to your local medical centre
It is important to get a blood test (Electrolytes) to check your blood sodium levels and
have your temperature checked.

High volume of clear urine and extreme thirst
This is called Diabetes insipidus. This is where there is a lack of antidiuretic
hormone release from the pituitary stalk. You will be going to the toilet regularly including
getting up multiple times at night. Please drink as determined by your thirst. It can be treated
with a nasal spray to replace ADH (Minrin). Please discuss with your Endocrinologist or GP

Nose bleeds
If you develop a bleeding nose, it is best to sit down and try and relax. Most
will stop on their own without intervention. Pinching the soft part of your nose or putting
some frozen peas / cold flannel over your face can help. If you continue to bleed and develop
large clots, then I would suggest going to your nearest medical centre / hospital where nasal
packs may need to be inserted.

Clear fluid from your nose
It is not uncommon to have some discharge from your nose for a few weeks
after surgery as the raw areas created during the operation, especially where the naso-septal
flap was elevated, progressively heal. However, a leak of CSF (Cerebrospinal fluid) is
possible. This will usually be identifiable as a constant drip of clear fluid when you tip your
head forward. If this keeps happening, it is sensible to go to your General Practitioner and
have the fluid checked for Beta2 transferrin (present only in CSF). Rarely, if this happens, we
may need to re-operate to seal the leak.

Consent

Surgery is a serious event that carries risk with it. Although utmost care is always taken around the surgery time, it is important to be aware of the possible risks, complications and implications of surgery. It is important that you discuss your operation fully with your surgeon BEFORE surgery and are aware of the procedure of surgery, the goals and possible outcomes of the surgery as well the risks and possible adverse outcomes.