How does surgery work?
Most operations on the pituitary gland are now carried out through the nose. This is called transsphenoidal surgery. ‘Trans’ means across and ‘sphenoid’ is the air cavity in which the pituitary gland sits, as you will see from our diagram at the beginning. Transsphenoidal surgery is traditionally performed using an operating microscope.
More recently technological advances have led to the use of fibre optic endoscopes in pituitary surgery. This is a newer technique and is called endoscopic pituitary surgery.
Operations through the skull (craniotomy) are far less common these days than they used to be. However, there are still situations where a craniotomy is required, for example, if parts of the tumour cannot be reached through the nose.
What will surgery achieve?
The aim of surgery is to remove as much of the tumour as safely as possible, without damage to the delicate nerves and blood vessels in the area. Surgery can, in some cases, remove all of the tumour if it is very small. Complete removal of large tumours can be difficult and inaccessible areas of the tumour will be left in place. For many people surgery is an essential part of your treatment to achieve ‘normal’ hormone balance.
Surgical treatment
With all surgical procedures there are some associated risks and potential complications. The choice of surgeon is crucial to the likelihood of successful removal of the tumour, with experienced pituitary surgeons having the best results. The duration of hospital stay depends on the type of surgery.
Some units like to transfer their patients back to the referring endocrinologist fairly soon after the operation for more detailed tests. Other units discharge the patient home and refer the patient to the endocrinologist as an outpatient.
What sort of surgery is undertaken?
The reason you have been referred for pituitary surgery is due to findings of an abnormality in or near to the pituitary gland; these can be called growths/tumours or adenomas. Please remember that the vast majority (over 99%), are benign, non-cancerous tumours. An explanation of your individual condition should have been discussed with you by your endocrinologist and/or neurosurgeon.
Most operations on the pituitary gland are performed through your nasal cavity (nostril), called transsphenoidal surgery. This is traditionally performed using an operating microscope. More recently, technological advances have led to the use of rigid endoscopes in pituitary surgery. This is a newer technique and is called endoscopic pituitary surgery. Often, neurosurgeons and ENT (Ear Nose and Throat) surgeons work together for this type of surgery.
Operations through the skull (craniotomy) are far less common these days than they used to be. However, there are still situations where a craniotomy is required, for example, if parts of the tumour cannot be reached through the nose.
How will I feel after my pituitary surgery?
Every individual responds differently, but it is important to remember that just because you do not have a visible scar, you have still had major surgery and a general anaesthetic.
Like most surgical procedures involving a general anaesthetic, there is likely to be an overall effect on your body, this is different for each person. The body takes some time to recuperate and repair and it is easy to expect this to happen more quickly than it actually does. How well you are prior to surgery can also affect your post-operative recovery.
Replacement hormone therapies may have been started before surgery and are still given as routine in some units. As a result of this you may be feeling an overall improvement in your health. Others may still be waiting to see if their hormones will recover naturally following surgery. It is not always appropriate to replace hormones prior to surgery, so don’t worry if you have not been prescribed these.
Immediately after the operation
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When you wake up from the operation, you will initially be in the recovery area of theatre. When your overall condition is stable, and you are relatively awake and responsive, you will be transferred to a neurosurgical ward or high dependency unit. (This depends on your hospital setting). It is very unlikely you will need to go to intensive care.
You will probably need to breathe through your mouth; this can be quite frightening initially but you will soon relax and find that you will manage this well. Taking a supply of lip salve in with you can help prevent dry and cracked lips. You will probably have a sore, painful nose. It can depend on how the operation goes, as to whether any packing in your nose is necessary. The length of time this remains in place depends on the individual’s surgery and is dictated by the surgeon, but in general, this will be removed within the first couple of days. This can be uncomfortable, but is performed quickly and you can have painkillers if required.
Initially, you will have your vital signs monitored frequently i.e. blood pressure, pulse and temperature. You will be attached to a cardiac monitor and have an intravenous infusion of clear fluids and oxygen therapy. You will also be questioned frequently to ensure you are alert mentally. These are all standard procedures and observations following surgery and a general anaesthetic.
Your doctors need to know that the surgery has not upset the mechanism that helps to control the volume of urine you make. You will have your urine output and fluid intake measured. This is because pituitary surgery can sometimes affect your ability to retain water, this is called AVP Deficiency (Diabetes Insipidus). If this occurs, it usually settles down after a few days. However, it may last longer and need hormone medication treatment.
Following the operation, most patients experience headaches or discomfort after surgery for a few days. You will be prescribed pain relief, so please ensure you inform the nursing staff if you have pain or discomfort.
Let a doctor know if there is any leakage of clear fluid from your nose or you are frequently swallowing a salty liquid from the back of your throat. This is known as a CSF leak and can be a complication following pituitary surgery.
Sometimes it is necessary to use packing in the area where they have removed the growth and this can be done using a special surgical sponge or they may take a piece of fat (fat graft) from your thigh or abdomen. If this is the case you will have a small wound. This heals well and you should not experience any complications from it. Ask for pain relief if this area is tender/sore.
You may be prescribed antibiotics to prevent any infection (as the risk of meningitis developing is increased if you have a CSF leak). You should be up and out of bed sitting in a chair and possibly walking to the toilet/shower etc. on your first post-op day.
Each day following surgery, brings an improvement in how you feel. Most people feel fine but some people feel extremely tired, wiped out and scared of what may lie ahead of them; others feel instant relief, especially if there has been improvement of previous headache or loss of vision.
If there was previous visual impairment prior to surgery it is important to remember that although the majority improve, it may take some time for any improvement to be noticed by you. Your surgeon will almost certainly check your vision as soon as you wake up. If you feel your vision is worse, which is fortunately very rare, you should let your doctors know, as this should lead to an early repeat scan
There will be numerous blood tests taken on the days you are in hospital and this is to assess your hormone production and to decide whether you need to be given medication to take home with you.
You may be given cortisol replacement therapy and you should be instructed on how to take these tablets. Importantly, you should be advised how to increase this medication during illness or stress.
NB: If you are sent home taking hydrocortisone it is very important that you continue to take it. Your GP will continue to prescribe this until you are seen in clinic for your first post-op assessment
Do not run out of hydrocortisone and do not stop taking it without instruction from your endocrinologist
Being Discharged
On your discharge home, it is understandable that you will feel anxious and concerned that all will be well and what to expect in regards to your recovery, but you will feel more confident as the days pass.
You must avoid blowing your nose for two weeks after surgery. This is to avoid putting pressure directly on the healing operation site. Avoid sneezing if possible, but if in the event you have to sneeze, try and do this through your open mouth with your nose uncovered.
It is normal for your nose to feel stuffy and blocked; this can take some weeks to improve.
NB: Please contact your neurosurgeon, about the following information and product use, to ask if it applies in your individual case:
Nasal crusting can be minimised by the regular use of nasal douches (rinsing) to wash out the nose four times daily. Start douching one week after surgery (or as advised by your medical staff) and continue for at least six weeks. You may then reduce the frequency of douches to twice daily, but it is advisable to continue doing this for three months. Nasal douches are effectively delivered using the NeilMed Sinus Rinse system, which can be purchased from your local chemist. (Please ask your GP as you may be entitled to have these on prescription). If dryness and crustiness persists, despite nasal douches, then use NeilMed NasoGel for dry noses, which can be used to soothe and rehydrate the nasal passages.
Your sense of smell, and thus taste, may be altered but hopefully over time this will improve. However, for a few people this doesn’t return to what it was before. This might be more likely with endoscopic procedures.
Avoid heavy lifting, heavy housework, and bending or straining on the toilet. If you are constipated please ask your GP to prescribe laxatives. It is generally recommended that you avoid swimming with the head below the water for three months, due to risk of infection. Although this is generally sensible, it is extremely unlikely that swimming will cause you any danger.
If you are having difficulty sleeping, try sitting up in a chair/recliner or use several pillows to raise your head and shoulders. We recommend you space out your activities at first and give yourself plenty of rest periods. You may increase your activities as you are able to tolerate them and as your endurance increases.
Returning to work
How quickly you can return to work depends on your type of job, but we would strongly recommend that you take at least two to six weeks off. Although you may be able to work at home, this should be discussed with your surgeon.
Travel
Your ability to drive is dependent on whether you have had any visual disturbance. If your vision has been impaired, you are duty bound to advise the DVLA of this fact and post-surgery you will need to be reassessed formally by ophthalmology department prior to resuming driving.
Avoid long distance travel in the initial weeks post operatively and general advice is not to fly for six weeks. If this is unavoidable then please discuss with your surgeon.
Review/follow up
You should have been given contact numbers for your neurosurgical / ENT / and endocrinology departments. Find out if your hospital has an Endocrine Specialist Nurse (if you have not already met them) and ensure you have their contact details.
Review and follow-up plans may vary at your individual hospital, but remember, you should always be reviewed following pituitary surgery.
One month post-operatively
ENT (if involved in your care) may request an appointment for you within the first month to check your nasal passages. This is done using a special “scope and camera” that may be ‘flexible’ or ‘rigid’ which is inserted into your nostril. This enables them to view this area on a screen. This may feel uncomfortable, but is generally well tolerated and is usually a quick process.
Six to eight weeks post-operatively
A review with your endocrinologist should be carried out to assess your pituitary function and the ability of hormone production. If you have not heard by six weeks post-op about your appointment, please contact the unit and ensure you are on the waiting list. Neurosurgical review is usually within the first couple of months.
A follow up MRI or CT scan will be booked following surgery, although the exact timing varies between units. Some neurosurgeons request an early MRI following surgery whilst others wait at least three months post operatively. This allows for swelling and inflammation from the surgery to subside. If you have had a hormone condition completely resolved following surgery, there is no need to check with a scan at all, although it will probably still be requested as part of a routine.
Further and subsequent follow up will be decided on an individual basis and also dependant on the medication you require (if any).
Once you have been diagnosed with a pituitary tumour you should always be kept under specialist endocrine review, especially if you are on replacement hormone medication. This is to be sure your medication is giving you the correct level of replacement hormones and also to check that your pituitary tumour is stable. Although they are benign tumours and grow slowly they can occasionally regrow in the years after surgery and may need further treatment.
