Anterior petrosectomy

see Anterior transpetrosal approach.

see also Extended anterior petrosectomy.

Jung et al. hypothesized that if anterior petrosectomy is performed with a three-dimensional understanding of the Kawase pyramid, it would have a positive effect on the extent of tumor resection.

They performed a retrospective study of patients who underwent surgical treatment for meningioma through an anterior petrosal approach. Patients were divided into total resection and subtotal resection groups, and statistical differences between the two groups were analyzed. To identify factors predictive of complete tumor removal, univariable and multivariable logistic regression analyses were performed.

The width and height of the drilled internal acoustic canal (IAC) of the total resection group were significantly longer than those of the subtotal resection group (p=0.001, p=0.033). The operative angle of the total resection group was significantly larger than that of the subtotal resection group (p<0.001). Regression analyses showed only drilled IAC width to be predictive of complete tumor removal, increasing the likelihood thereof by 2.778-fold with an increase in drilled IAC width by 1 mm (p=0.023).

Insufficient petrosectomy during an anterior petrosal approach adversely affects the extent of tumor resection. Furthering three-dimensional understanding of the Kawase pyramid could help complete tumor resection and better outcomes without causing damage to the surrounding organs ¹⁾.

The anterior petrosectomy with preoperative embolization of the inferior petrosal sinus is a time-conserving approach giving one of the best routes to reach the ventral brainstem while working in front of the cranial nerves and preserving hearing ²⁾.

Identification and protection of the cochlea during anterior petrosectomy is key to prevent hearing loss. Currently, there is no optimal method to infer the position of the cochlea in relation to the Kawase quadrangle, therefore damage to the cochlea during anterior petrosectomy remains a substantial risk.

In a simulated surgical setting using human cadavers, a trial was conducted with 5 expert skull base surgeons from 3 different hospitals. They performed 10 AP approaches, using either the feedback method or standard image guidance. Damage to critical structures was assessed. Operative time, drill cavity sizes, and proximity of postoperative drill cavities to the cochlea and the internal acoustic meatus, were measured. Questionnaires were obtained postoperatively. Errors in the virtual drill cavities as compared with actual postoperative cavities were calculated. In a clinical setup, the method was used during AP.

Surgeons rated their intraoperative orientation significantly better with the feedback method compared with standard image guidance. During the cadaver trial, the cochlea was harmed on 1 occasion in the control group, while surgeons drilled closer to the cochlea and meatus without injuring them in the group using feedback. Virtual drilling under- and overestimation errors were 2.2 ± 0.2 and -3.0 ± 0.6 mm on average. The method functioned properly during the clinical setup.

The proposed feedback method improves orientation and surgical performance in an experimental setting. Errors in virtual drilling reflect spatial errors of the image guidance system. The feedback method is clinically practicable during AP ³⁾.

Kawase approach was simulated in eleven specimens. After a subtemporal approach, foramen spinosum and foramen ovale were identified. Anterior petrosectomy was performed and the upper dural transitional fold (UDTF) was identified. Two virtual lines, from foramen spinosum (Line A), and the lateral rim of the foramen ovale (Line B), were projected to intersect the UDTF perpendicularly. The cochlea was exposed and the distances between Lines A and B and the closest point of the outer rim and membranous part of the cochlea were measured.

The average distance between Line A to the bony and membranous edges of the anteromedial cochlea was -0.62±1.38 mm and 0.38±1.63 mm, respectively. The average distance between Line B to the bony and membranous edges of the cochlea was 1.82±0.99 mm and 2.78±1.29 mm, respectively. Line B (cochlear safety line) never intersected the cochlea.

The cochlear safety line is a reliable landmark to avoid the cochlea during the Kawase approach. When expanding the anterior petrosectomy posteriorly, the “cochlear safety line” may be used as a reliable landmark to prevent exposure of the cochlea, therefore preventing hearing loss ⁴⁾.

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