Combined presigmoid approach: A literature review.

Background: The presigmoid approach represents the standard route to reach the petrous area anterior to the sigmoid sinus. Several lateral skull base approaches have been integrated into this approach for the purpose of widening the window, leading to variable combined approaches and variable terminology. Herein, the authors conducted a systematic review of the literature to simplify understanding of the potential combination of different approaches and their complications.

Methods: PubMed, EMBASE and Web of Science databases were searched on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to include studies describing modifications of the presigmoid approach.

Results: We included 27 studies comprising 545 patients. Five combination types applied to the presigmoid approach were identified: Anterior petrosal (Kawase's) approach (Type-1), Supra-tentorial approach (Type-2), Infratemporal fossa approach (Type-3), retrosigmoid approach (Type-4), and Far-lateral suboccipital approach (Type-5). Type-1 combined approach was the commonest type (n = 204, 37.5%), followed by type-2 (n = 197, 36%), type-4 (n = 54, 9.9%), type-5 (n = 51, 9.4%), and type-3 (n = 39, 7.2%). Meningioma was the typical target lesion in all types except type 3, where it is solely used for paraganglioma. The petroclival region was the prevalent access location in all the types of combined presigmoid approaches (type-1, 92%; type-2, 95%; type-3, 100%; type-4, 59%; and type-5, 64%). The intraoperative lateral patient position was dominantly utilized in type-1, type-3, and type-5 approaches (65%, 100%, and 100%, respectively), while park-bench was the most common position in type-2 (36%) and type-4 (100%) approaches. Overall, all types exhibited good outcomes in the form of gross total resection of the lesion and the absence of surgical complications in the follow-up.

Conclusion: Presigmoid approaches are becoming increasingly complex with the application and integration of the lateral skull base approaches, resulting in broadening the surgical field and easy access to the targeted lesions. The importance of designing a comprehensive nomenclature of the combined presigmoid approaches may add distinctive contributions to the growing knowledge of neurosurgery.