Uninostril endonasal trans-sphenoidal approach for pituitary macroadenoma–Operative nuances step by step

The Uninostril Endonasal Transsphenoidal approach stands out for its ability to preserve nasal anatomy, ensuring normal postoperative breathing while reducing postoperative nasal complications. The Uninostril approach offers a simplified access, expedites both the nasal phase and closure, all while leaving the contralateral nostril untouched, allowing for a potential rescue flap if needed. This method is particularly suited for primary cases of sellar suprasellar Knosp 0/1 pituitary adenomas located medial to the carotid arteries and with T2 iso to hyperintense signals on the MRI. The objective of this article is to elucidate the operative step by step nuances of the uninostril endonasal trans-sphenoidal surgery.

The patient positioning is key with a neutral head alignment positioned above the heart level and slightly tilted to the opposite side. This position is ergonomically better, reduces the venous bleeding, and enhances gravity-assisted tumor removal. Despite its advantages—such as improved postoperative nasal quality and a comparable rate of gross total tumor resection to the Bi-nostril approach—the Uninostril technique is not without limitations. Challenges include a restricted field of view, limited instrument maneuverability, and the potential need to convert to a Bi-nostril approach in cases of excessive bleeding or visualization difficulties. Overall, this approach provides a viable alternative for pituitary adenoma resection in selected subset of the patients, effectively balancing the oncologic resection and patient’s related outcomes.