Evaluating the effectiveness and complications of the Retrosigmoid, Translabyrinthine and Middle Fossa approaches in vestibular Schwannoma surgical management: a comprehensive systematic review and meta-analysis of 6,889 patients.

Abstract

Surgical resection stands as one of the potential therapeutic methods for vestibular schwannomas (VS). However, in the management of patients with VS, there is limited literature directly comparing the Retrosigmoid approach (RSA) with the Translabyrinthine Approach (TLA) and Middle Fossa Approach (MFA). This gap arises because the MFA is typically reserved for smaller intracanalicular tumors, while the RSA and TLA are preferred for larger lesions. Our objective was to assess and compare the outcomes and safety profile of these three different surgical approaches. A comprehensive search was performed on PubMed, Embase, and Cochrane Library for studies comparing RSA with TLA and MFA in patients with VS. The main outcomes of interest were hearing preservation, facial nerve function, extent of resection, and postoperative complications. Statistical analyses were performed using Review Manager. The I2 test was employed for heterogeneity assessment, while the risk of bias was evaluated utilizing ROBINS-I. We included 6,889 patients from 32 observational studies. RSA was used to manage VS in 3,352 (48,7%) patients. Our comparative hearing preservation analysis revealed no significant difference in patient improvement between RSA and MFA, with a risk ratio (RR) of 1.18 (95% CI: 0.76-1.85, p = 0.46, I2:0%). Late facial nerve preservation comparing RSA and TLA showed RR = 0.91(95% CI: 0.77-1.07, p = 0.25, I2:32%), while RSA with MFA a RR = 0.98 (95% CI: 0.92-1.04, p = 0.53, I2:87%). The cerebrospinal fluid (CSF) leak showed no significant difference in risk RR = 1.18 (95% CI: 0.92-1.51, p = 0.21; I2:0%) and RR = 1.14 (95% CI: 0.70-1.83; p = 0.60, I2:26%) comparing RSA with TLA and MFA respectively. The evidence synthesized in this meta-analysis suggests equivalent hearing preservation and facial nerve function in managing VS patients across the different RSA and MFA surgical approaches analyzed. However, in comparison to TLA and MFA, RSA stood out exhibiting fewer occurrences of postoperative complications consisting of hydrocephalus, and CSF leaks.