Impact of COVID-19 on pituitary surgery.

The emergence of coronavirus disease 2019 (COVID‐19) and the ensuing pandemic have altered every aspect of our healthcare system, including the care delivered to those patients who do not contract the virus. However, some non‐COVID‐19 patients will be more affected than others. In addition to appropriate restrictions in place as of 2 April 2020 in Australia, which limit elective surgical procedures to only those in category 1 (urgent, admission within 30 days) and high priority category 2 (semi‐urgent, admission within 90 days), there are now operations which are deemed too unsafe to be performed, even if urgent. The early experience in China and Italy has revealed an increased risk of contagion among ear, nose and throat surgeons and their teams performing aerosol‐generating procedures such as those involving the sinuses.1, 2, 3 This has implications for patients awaiting neurosurgery for lesions in the pituitary fossa and anterior skull base, which are frequently approached through trans‐sphenoidal and other endonasal trans‐sinus surgical corridors.

Throughout the world, there has been a strong recommendation to avoid trans‐sphenoidal approaches for pituitary tumours. International specialist societies including our own Neurosurgery Society of Australasia have recommended ‘serious consideration be given to avoiding a trans‐sphenoidal approach due to extremely high viral transmission risk’. Fortunately, most pituitary tumours are slow‐growing benign lesions and close monitoring with regular radiological imaging and visual assessment remains a viable option for pituitary tumour patients.

A small proportion of pituitary tumours however will require surgical intervention acutely due to deteriorating visual acuity or visual fields across serial ophthalmological assessment, as well as pituitary apoplexy causing rapid loss of vision including blindness. In these situations, consideration must be given to the surgical alternative of an open craniotomy to allow access to the pituitary tumour and decompression of the optic apparatus. Whilst the risk profile of a craniotomy is higher compared to that of a trans‐sphenoidal approach, the public health risk to the entire surgical team (doctors, nurses and technicians) and subsequently their contacts in proceeding with an aerosol‐generating trans‐sphenoidal surgery far outweighs the individual risk to the patient.

An even smaller proportion of pituitary tumours may present with acute medical manifestations due to hormonal imbalances. Where possible, these should be managed medically under close supervision of an endocrinologist. Fulminant Cushing's disease is the one rare situation whereby a short period of medical management might fail, and in this situation careful discussion with the treating medical and surgical team must be undertaken in the context of the COVID‐19 pandemic to guide surgical approach.

We are not suggesting that a craniotomy for a pituitary tumour is superior to a trans‐sphenoidal approach. Indeed, our extensive experience across three high‐volume pituitary centres confirms that visual and endocrine outcomes are optimized via the trans‐sphenoidal approach. Likewise, we are not suggesting that all pituitary tumours undergo a craniotomy; however, in the current climate of COVID‐19, we would strongly recommend a protocol of close monitoring of pituitary tumour patients and proceeding with a craniotomy for those patients who warrant urgent surgical intervention.

Finally, it is important to consider the psychology of the patient throughout this situation. Many pituitary tumour patients are well informed having been down a long journey to diagnosis, and to be told their surgical treatment will be delayed (indefinitely) or be considered for a craniotomy may impact on their mental well‐being. Having held several discussions with our current pituitary patients, it is important to reassure them of the safety of the current approach, to empathize with their situation and to be in regular contact with them during this period. Whilst we are acting for the good of the overall community, it can be a long and lonely path to walk for the individual patient affected by these decisions.