The Modified Sparing Binostril Endoscopic Endonasal Approach Combined With an Algorithm-Based Reconstruction Strategy: Surgical and Functional Outcomes in Sellar and Suprasellar Lesions

BACKGROUND AND OBJECTIVES: Conventional binostril endoscopic endonasal approaches (EEAs) provide optimal surgical ergonomics but are often associated with sinonasal morbidity. Conversely, mononostril approaches preserve mucosal integrity at the expense of surgical maneuverability. We hypothesized that the modified sparing binostril approach (moSBA) may provide a favorable balance between surgical exposure, ergonomics, and sinonasal preservation while maintaining flexibility for risk-adapted reconstruction. This study evaluates the feasibility and functional outcomes of this technique combined with a risk-adapted skull base reconstruction strategy. METHODS: We retrospectively reviewed 81 patients who underwent EEA or extended EEA for sellar and suprasellar lesions between 2021 and 2025. All procedures were performed combining a paraseptal and a contralateral endonasal corridor (moSBA). The risk-adapted reconstructive algorithm included type 1 (hemostatic material with free mucosal graft), type 2 (inlay fat graft with onlay nasoseptal flap), and type 3 (modified gasket-seal). Outcomes included extent of resection, complications, and 22-item Sinonasal Outcome Test (SNOT-22) assessment. RESULTS: EEAs were performed in 56 (69.1%) and extended EEAs in 25 (30.9%) patients. Intraoperative cerebrospinal fluid (CSF) leakage occurred in 48 cases (59.3%) and was graded as 1 in 12.3%, 2 in 34.6%, and 3 in 12.3%. Reconstruction types 1, 2, and 3 were used in 40.7%, 46.9%, and 12.4% of cases, respectively. Gross total resection was achieved in 72.9%. Postoperative CSF leakage occurred in 2.5%. On exploratory multivariate analysis, reconstruction complexity was independently associated with higher postoperative SNOT-22 score (B = 3.379, 95% CI: 0.827-5.930, P = .010). CONCLUSION: The moSBA appears to be a feasible and safe option for selected sellar and suprasellar lesions, providing favorable surgical and functional outcomes in this single-center experience. Although higher reconstruction complexity was independently associated with higher postoperative SNOT-22 scores, residual confounding related to surgical invasiveness, skull base defect magnitude, and intraoperative CSF leakage severity cannot be excluded.