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Objective When transsphenoidal surgery (TSS) does not cure Cushing's disease (CD), 4 treatments are available: drug treatment (DT), second TSS (2nd TSS), bilateral adrenalectomy (BA), and pituitary radiotherapy (PR). DT is attractive but supposes long-term continuation, which we aimed to evaluate. Design and Methods Retrospective study, in a center prioritizing 2nd TSS, of 36 patients, including 19 with TSS failure and 17 with recurrence, out of 119 patients with CD treated by a first TSS, average follow-up 6.1 years (95% confidence interval 5.27-6.91). Control was defined as normalization of urinary free cortisol (UFC) and final treatment (FT) as the treatment allowing control at last follow-up. We also analyzed discontinuation rates of DT in published CD prospective clinical trials. Results Control was achieved in 33/36 patients (92%). DT was initiated in 29/36 patients (81%), allowing at least 1 normal UFC in 23/29 patients (79%) but was discontinued before last follow-up in 18/29 patients (62%). DT was FT in 11/29 patients (38%), all treated with cortisol synthesis inhibitors. Second TSS was FT in 8/16 (50%), BA in 14/14 (100%), and PR in 0/5. In published trials, discontinuation of DT was 11% to 51% at 1 year and 32% to 74% before 5 years. Conclusion DT allowed at least 1 normal UFC in 23/29 patients (79%) but obtained long-term control in only 11/29 (38%), as discontinuation rate was high, although similar to published data. Interestingly, a successful 2nd TSS was the cause for discontinuing efficient and well-tolerated DT in 5 patients. Further studies will show whether different strategies with cortisol synthesis inhibitors may allow for a lower discontinuation rate in patients not candidates for a 2nd TSS so that BA may be avoided in these patients. [ABSTRACT FROM AUTHOR]

Background and Objectives: Aneurysmal surgery is technically complex, and surgeon experience is an important factor in therapeutic success, but training young vascular neurosurgeons has become a complex paradigm. Despite new technologies and simulation models, cadaveric studies still offer an incomparable training tool with perfect anatomic accuracy, especially in neurosurgery. The use of human placenta for learning and improving microsurgical skills has been previously described. In this article, we present a comprehensive simulation model with both realistic craniotomy exposure and vascular handling consisting of a previously prepared and perfused human placenta encased in a human cadaveric specimen., Methods: Humans' placentas from the maternity and cadaveric heads from the body donation program of the anatomy laboratory were used. Placentas were prepared according to the established protocol, and aneurysms were created by catheterization of a placental artery. Ten participants, including senior residents or young attendees, completed an evaluation questionnaire after completing the simulation of conventional unruptured middle artery aneurysm clipping surgery from opening to closure., Results: The skin incision, muscle dissection, and craniotomy were assessed as very similar to reality. Brain tissue emulation and dissection of the lateral fissure were judged to be less realistic. Vascular management was evaluated as similar to reality as closure. Participants uniformly agreed that this method could be implemented as a standard part of their training., Conclusion: This model could provide a good model for unruptured aneurysm clipping training., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)