Endonasal endoscopic surgery for residual or recurrent craniopharyngiomas: A propensity score-matched cohort study

Craniopharyngiomas (CPs) frequently recur even after gross total resection (GTR), posing substantial challenges to long-term disease control. Endoscopic endonasal surgery (EES) has become a widely adopted approach for CPs, yet its efficacy for recurrent or residual lesions remains controversial. This study aimed to evaluate the efficacy and safety of repeat EES for recurrent or residual CPs by comparing surgical, functional, and long-term outcomes with those of primary EES. We retrospectively reviewed CP patients who underwent EES at our center between June 2012 and December 2024. Patients were categorized into primary and repeat EES groups. Baseline characteristics, surgical outcomes, perioperative complications, and long-term results were compared. To reduce potential confounding, a 1:2 propensity score-matched (PSM) analysis was performed based on key clinical covariates. Before matching, 213 patients were included; after PSM, 92 patients underwent primary EES and 46 underwent repeat EES. Compared with primary EES, repeat EES was associated with a significantly lower GTR rate (87.0% vs. 96.7%, p = 0.04) and higher recurrence rate (7.0% vs. 0.0%, p = 0.03). Kaplan-Meier analysis demonstrated shorter recurrence-free survival in the repeat group. Among patients with preoperative visual impairment, visual improvement was less frequent in the repeat group (48.5% vs. 71.9%, p = 0.02). Rates of visual deterioration, new visual deficits, perioperative complications, and endocrinological outcomes did not differ significantly between groups. Compared with primary EES, repeat EES for recurrent or residual CPs yields lower GTR rates and higher recurrence rates, while achieving comparable visual, endocrinological, and complication profiles. These findings suggest that, despite reduced resection rates, repeat EES remains a viable and safe therapeutic option for selected patients with recurrent or residual CPs.