This study did not receive any funding.

The Institutional Review Committee of the Istanbul Faculty of Medicine approved the study protocol. Before the start of the study, the patient was asked to sign an informed consent form outlining the purpose of use and publication of their data.
1. Preoperative procedures
<ol>
	<li>Perform the operations under general anesthesia. Prepare endoscopic and optical equipment in the operating room.</li>
	<li>Check the instruments before starting the procedure (<strong class="xfig"...

Endoscopy from Kocher&#39;s Point Enabling Third Ventriculostomy and Pineal Biopsy

<ol>
	<li>Favero, G., Bonomini, F., Rezzani, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pineal+gland+tumors:+A+review.">Pineal gland tumors: A review.</a> Cancers (Basel). 13 (7), 1547 (2021).</li><li>Nagasawa, D. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pineal+germ+cell+tumors:+Two+cases+with+review+of+histopathologies+and+biomarkers.">Pineal germ cell tumors: Two cases with review of histopathologies and biomarkers.</a> J Clin Neurosci. 38, 23-31 (2017).</li><li>Tamrazi, B., Nelson, M., Bl&#252;ml, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pineal+region+masses+in+pediatric+patients.">Pineal region masses in pediatric patients.</a> Neuroimaging Clin N Am. 27 (1), 85-97 (2017).</li><li>Carr, C., O'Neill, B. E., Hochhalter, C. B., Strong, M. J., Ware, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biomarkers+of+pineal+region+tumors:+A+review.">Biomarkers of pineal region tumors: A review.</a> Ochsner J. 19 (1), 26-31 (2019).</li><li>Iorio-Morin, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histology-stratified+tumor+control+and+patient+survival+after+stereotactic+radiosurgery+for+pineal+region+tumors:+A+report+from+the+international+gamma+knife+research+foundation.">Histology-stratified tumor control and patient survival after stereotactic radiosurgery for pineal region tumors: A report from the international gamma knife research foundation.</a> World Neurosurg. 107, 974-982 (2017).</li><li>Liu, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simultaneous+single-trajectory+endoscopic+biopsy+and+third+ventriculostomy+in+pediatric+pineal+region+tumors.">Simultaneous single-trajectory endoscopic biopsy and third ventriculostomy in pediatric pineal region tumors.</a> Acta Neurol Belg. 121 (6), 1535-1542 (2021).</li><li>Attri, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+third+ventriculostomy+and+simultaneous+tumor+biopsy+in+pineal+region+tumors+using+the+&amp;#34;single+burr+hole&amp;#34;+technique:+An+analysis+of+34+cases.">Endoscopic third ventriculostomy and simultaneous tumor biopsy in pineal region tumors using the &amp;#34;single burr hole&amp;#34; technique: An analysis of 34 cases.</a> Asian J Neurosurg. 15 (4), 976-982 (2020).</li><li>Abbassy, M., Aref, K., Farhoud, A., Hekal, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcome+of+single-trajectory+rigid+endoscopic+third+ventriculostomy+and+biopsy+in+the+management+algorithm+of+pineal+region+tumors:+A+case+series+and+review+of+the+literature.">Outcome of single-trajectory rigid endoscopic third ventriculostomy and biopsy in the management algorithm of pineal region tumors: A case series and review of the literature.</a> Childs Nerv Syst. 34 (7), 1335-1344 (2018).</li><li>Fukushima, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+biopsy+of+intraventricular+tumors+with+the+use+of+a+ventriculofiberscope.">Endoscopic biopsy of intraventricular tumors with the use of a ventriculofiberscope.</a> Neurosurgery. 2 (2), 110-113 (1978).</li><li>Kawsar, K. A., Haque, M. R., Chowdhury, F. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Avoidance+and+management+of+perioperative+complications+of+endoscopic+third+ventriculostomy:+The+Dhaka+experience.">Avoidance and management of perioperative complications of endoscopic third ventriculostomy: The Dhaka experience.</a> J Neurosurg. 123 (6), 1414-1419 (2015).</li><li>Yang, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+third+ventriculostomy+and+biopsy+of+a+tectal+lesion+using+flexible+neuroendoscopy+and+urological+cup+forceps:+Illustrative+case.">Endoscopic third ventriculostomy and biopsy of a tectal lesion using flexible neuroendoscopy and urological cup forceps: Illustrative case.</a> J Neurosurg Case Lessons. 5 (16), CASE22517 (2023).</li><li>Revuelta Barbero, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Combined+microsurgical-endoscopic+paramedian+supracerebellar-infratentorial+approach+for+resection+of+a+pineal+low-grade+glioma.">Combined microsurgical-endoscopic paramedian supracerebellar-infratentorial approach for resection of a pineal low-grade glioma.</a> Neurosurg Focus Video. 5 (1), V9 (2021).</li><li>Al-Saiari, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simultaneous+biportal+endoscopic+management+of+pineal+region+tumors+in+patients+with+obstructive+hydrocephalus:+Technical+notes.">Simultaneous biportal endoscopic management of pineal region tumors in patients with obstructive hydrocephalus: Technical notes.</a> Chin Neurosurg J. 9 (1), 1 (2023).</li><li>Birski, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+versus+stereotactic+biopsies+of+intracranial+lesions+involving+the+ventricles.">Endoscopic versus stereotactic biopsies of intracranial lesions involving the ventricles.</a> Neurosurg Rev. 44 (3), 1721-1727 (2021).</li><li>Gurusamy, S. M., Yaakub, A., Wan Hitam, W. H., Ahmad Maulana, S. A., Wan Ibrahim, W. Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pineal+gland+tumour+with+drop+metastases:+A+case+report.">Pineal gland tumour with drop metastases: A case report.</a> Cureus. 14 (10), e29855 (2022).</li><li>Panyaping, T., Tritanon, O., Wisetsathon, P., Chansakul, T., Pongpitcha, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+of+apparent+diffusion+coefficient+values+for+distinguishing+between+pineal+germ+cell+tumour+and+pineoblastoma.">Accuracy of apparent diffusion coefficient values for distinguishing between pineal germ cell tumour and pineoblastoma.</a> Clin Radiol. 78 (7), e494-e501 (2023).</li><li>Leone, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Concomitant,+single+burr+hole+endoscopic+third+ventriculostomy+and+tumor+biopsy+for+pineal+lesions:+Feasibility,+safety,+and+benefits.">Concomitant, single burr hole endoscopic third ventriculostomy and tumor biopsy for pineal lesions: Feasibility, safety, and benefits.</a> World Neurosurg. 173, 5-11 (2023).</li><li>Morgenstern, P. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pineal+region+tumors:+An+optimal+approach+for+simultaneous+endoscopic+third+ventriculostomy+and+biopsy.">Pineal region tumors: An optimal approach for simultaneous endoscopic third ventriculostomy and biopsy.</a> Neurosurg Focus. 30 (4), E3 (2011).</li><li>Zhang, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+hydrocephalus+secondary+to+pineal+region+tumors.">Management of hydrocephalus secondary to pineal region tumors.</a> Clin Neurol Neurosurg. 115 (9), 1809-1813 (2013).</li><li>Xin, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic-assisted+surgery+versus+microsurgery+for+pineal+region+tumors:+A+single-center+retrospective+study.">Endoscopic-assisted surgery versus microsurgery for pineal region tumors: A single-center retrospective study.</a> Neurosurg Rev. 44 (2), 1017-1022 (2021).</li><li>Choque-Velasquez, J., Resendiz-Nieves, J., Colasanti, R., Hernesniemi, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+obstructive+hydrocephalus+associated+with+pineal+region+cysts+and+tumors+and+its+implication+in+long-term+outcome.">Management of obstructive hydrocephalus associated with pineal region cysts and tumors and its implication in long-term outcome.</a> World Neurosurg. 149, e913-e923 (2021).</li><li>Chibbaro, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neuroendoscopic+management+of+posterior+third+ventricle+and+pineal+region+tumors:+Technique,+limitation,+and+possible+complication+avoidance.">Neuroendoscopic management of posterior third ventricle and pineal region tumors: Technique, limitation, and possible complication avoidance.</a> Neurosurg Rev. 35 (3), 338-340 (2012).</li><li>Ahmed, A. I., Zaben, M. J., Mathad, N. V., Sparrow, O. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+biopsy+and+third+ventriculostomy+for+the+management+of+pineal+region+tumors.">Endoscopic biopsy and third ventriculostomy for the management of pineal region tumors.</a> World Neurosurg. 83 (4), 543-547 (2015).</li></ol>

The description of the ETV and biopsy for pineal tumors was first described in the 1970s. Historically, the fear of uncontrolled hemorrhage has always existed. However, owing to advances in endoscopic surgery techniques, bleeding control is not a major complication for experienced surgeons nowawadays9,10. According to several cases in the literature, endoscopic management has been found to be effective as an initial step for pineal region tumors presenting with h...

The pineal gland is a neuroendocrine gland located in the epithalamus that is responsible for regulating biological rhythms in vertebrates. Its anatomical boundaries include the posterior surface of the wall of the third ventricle, which forms the base of the gland, the splenium of the corpus callosum superiorly, and the thalamus surrounding both sides. It has a pinecone shape and extends posteriorly and inferiorly in the quadrigeminal cistern1,2. 
Pineal neoplasms are relatively rare tumors and are predominantly childhood malignancies, accounting for 3-11% of all childhood brain tumors compared with &lt;1% of adult brain tumors1,3,4. Age, sex, and ethnicity can modify the relative incidence of pineal neoplasms5. Pineal tumors are classified into three types: germ cell tumors, pineal parenchymal tumors, and tumors arising from neighboring anatomical regions. Germinomas are the most frequent pineal tumors, accounting for up to 50% of pineal tumors in Europe1,3.
Tumors of the pineal gland are pathologically diverse and their optimal management remains controversial6. Advances in neuroendoscopy have significantly contributed to treating pineal region tumors. Neuroendoscopic techniques are minimally invasive, effective, and safe in treating these tumors. With this technique, it is possible to treat hydrocephalus and obtain a biopsy simultaneously7. In most cases, simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is the first-choice surgical procedure for pineal region tumors due to the effectiveness of radiotherapy and chemotherapy in most histopathological subtypes. Various techniques for simultaneous ETV and biopsy have been described, and there is currently no standard technique for performing this procedure8.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Adson periosteal elevator</td>
			<td>Ruggles-Redmond</td>
			<td>RO263</td>
			<td>Semi-sharp, 5 mm, curved 6-3/8, length 164 mm</td>
		</tr>
		<tr>
			<td>Automatic skin retractors&#160;</td>
			<td>Integra</td>
			<td>3,72,245</td>
			<td>Heiss Automatic Skin Retractor Length - Overall (mm): 102 
			Length 1 - Tip/Jaw (mm): 8</td>
		</tr>
		<tr>
			<td>Balloon catheter&#160;</td>
			<td>Edwards Fogarty</td>
			<td>120804FP</td>
			<td>Length (cm): 80, Catheter size (F): 4,&#160; Inflated balloon diameter (mm): 9</td>
		</tr>
		<tr>
			<td>Biopsy Forceps</td>
			<td>Karl Storz LOTTA CLICKLINE Grasping Forceps</td>
			<td>28164 LE</td>
			<td>Rotating, dismantling, single action jaws, diameter 2.7 mm, working length 30 cm</td>
		</tr>
		<tr>
			<td>Bipolar coagulation electrode</td>
			<td>Karl Storz LOTTA</td>
			<td>28161 SF</td>
			<td>Diameter 1.3 mm, working length 30 cm</td>
		</tr>
		<tr>
			<td>Bisture</td>
			<td>Beybi</td>
			<td>24,02,502</td>
			<td>Beybi Bisture Tip. No: 20 and No: 11</td>
		</tr>
		<tr>
			<td>High-speed drill</td>
			<td>Medtronic Midas Rex MR8</td>
			<td>MR8&#8482; Electric Plus EM850</td>
			<td>Perforator tip used</td>
		</tr>
		<tr>
			<td>Obturator</td>
			<td>Karl Storz LOTTA</td>
			<td>28164 LLO</td>
			<td>Use with Operating Sheaths for ventricular puncture</td>
		</tr>
		<tr>
			<td>Operating sheath</td>
			<td>Karl Storz LOTTA</td>
			<td>28164 LSB</td>
			<td>Graduated, rotating, outer diameter 6.8 mm, working length 13 cm</td>
		</tr>
		<tr>
			<td>Ventriculoscope</td>
			<td>Karl Storz LOTTA Ventriculoscope with HOPKINS</td>
			<td>28164 LAB</td>
			<td>Wide angle telescope 30&#176;, angled eyepiece, outer diameter 6.1 mm, length 18 cm, working channel diameter 2.9 mm, irrigation/suction channel diameter 1.6 mm</td>
		</tr>
	</tbody>
</table>

endoscopic third ventriculostomy and pineal biopsy from a single entry point

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain tumors, which is considerably higher than the &lt;1% seen in adult brain tumors. These tumors can be divided into three main categories: germ cell tumors, parenchymal pineal tumors, and tumors arising from related anatomical structures. Obtaining an accurate and minimally invasive tissue diagnosis is crucial for selecting the most appropriate treatment regimen for patients with pineal gland tumors. This is due to the diverse treatment options available and the potential risks associated with complete resection. In cases where patients present with acute obstructive hydrocephalus caused by a pineal gland tumor, immediate treatment of the hydrocephalus is necessary. The urgency stems from the potential complications of hydrocephalus, including increased intracranial pressure and neurological deficits. To address these challenges, a minimally invasive endoscopic approach provides a valuable opportunity. This technique allows clinicians to promptly relieve hydrocephalus and obtain a histological diagnosis simultaneously. This dual benefit enables a more comprehensive understanding of the tumor and assists in determining the most effective treatment strategy for the patient.

Author Spotlight: A Single-Entry Point Endoscopic Intraventricular Approach for Third Ventriculostomy and Pineal Biopsy

Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point

Endoscopic intraventricular approach are widely used in neurosurgery. Here we describe the full endoscopic technique for third ventriculostomy and pineal biopsy from a single entry point in patient that had obstructive hydrocephalus due to pineal lesions. So endoscopic systems contains one channel and one irrigation channel.Bipolar coagulation, nerve balloon, and micro forceps are sufficient for the procedure. The advantage of advanced technology has enabled the acquisition of high definition HDI 4K quality images during endoscopic surgeries. Angled and flexible endoscope facilitate more effective work in smaller areas, enhancing the precision and efficiency of surgical procedures.

Preoperative magnetic resonance imaging (MRI) revealed a pineal tumor and triventricular hydrocephalus. Before the surgery, we ensured that our endoscope set, 4F Fogarty balloon catheter (see Figure 1), and all required materials (see Table 1) were checked. The size of the pineal tumor was initially measured at 30 mm x 15 mm x 20 mm. However, on postoperative MRI scans, it was observed that the tumor had increased in size to 35 mm x 52 mm x 45 mm, suggesting...

Pineal neoplasms frequently cause obstructive hydrocephalus and require histopathological diagnosis to decide the treatment regimen. They might be treated by surgical resection or chemoradiotherapy according to the pathological diagnosis. As a minimally invasive initial treatment, an endoscopic approach from Kocher's point enables both third ventriculostomy and biopsy.

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain ...