Two-stage surgery for cystic craniopharyngiomas: a purely endoscopic strategy and outcomes

This study aimed to evaluate the effectiveness and safety of two-stage endoscopic surgery for the complete resection of cystic craniopharyngiomas.

We retrospectively evaluated 11 patients who underwent two-stage endoscopic surgery between March 2020 and July 2025. The lesions showed suprasellar and lateral extension toward the optic chiasm or the foramen of Monro, resulting in visual impairment or obstructive hydrocephalus. Cyst fenestration (CF) was initially performed using a transventricular approach with a flexible endoscope. One to two months later, endoscopic transsphenoidal surgery (eTSS) was performed to achieve complete resection. Tumor size (vertical diameter, horizontal diameter, and volume) was measured at three time points: pre-CF, post-CF (≤ 4 days), and pre-eTSS. Extent of resection, recurrence, and pituitary and hypothalamic function were assessed post-eTSS.

Complete resection was achieved in 10 of 11 patients, with no recurrence during a median follow-up of 22.8 months (range, 3.6-65.3). At a median interval of 54 days (range, 27-86) between CF and eTSS, the mean linear reduction was 45.3% superiorly and 39.3% laterally; mean tumor volume decreased by 68.0%. In some cases, areas typically difficult to access via eTSS alone decreased in size. All preoperative symptoms, except for hypopituitarism and diabetes insipidus, improved immediately after CF. No hypothalamic dysfunction was observed.

Two-stage endoscopic surgery for cystic craniopharyngiomas is effective and safe, enabling complete resection with low recurrence during short- to mid-term follow-up.