Resection versus fenestration for Rathke's cleft cysts: a propensity score-matched analysis of long-term outcomes

Area of Science:

• Neurosurgery
• Endocrinology
• Sellar Lesions

Background:

• Rathke's cleft cysts (RCCs) are common benign sellar tumors.
• Surgical intervention for RCCs aims to alleviate symptoms like visual deficits, endocrinopathy, and headaches.
• The choice between cyst fenestration and cyst wall resection involves balancing recurrence prevention against potential endocrine complications.

Purpose of the Study:

• To compare the long-term surgical outcomes of cyst fenestration versus cyst wall resection for Rathke's cleft cysts.
• To evaluate recurrence rates and the impact on visual, endocrine, and headache symptoms for each surgical approach.

Main Methods:

• A single-center retrospective analysis of 278 patients with pathology-confirmed RCCs treated between 2000 and 2023.
• Patients underwent either cyst fenestration or resection (gross-total [GTR] or subtotal [STR]).
• Propensity score matching was used to compare outcomes, with recurrence analyzed via Kaplan-Meier curves and Cox regression.

Main Results:

• Fenestration was associated with larger initial cyst size compared to resection.
• Similar rates of visual and endocrine symptom improvement were observed between fenestration and resection.
• Resection (GTR/STR) showed lower headache resolution rates and higher rates of new growth hormone (GH) deficiency compared to fenestration, especially in cysts ≤ 15 mm.
• Postoperative residual cyst was the strongest predictor of recurrence; STR was linked to more rapid recurrence than GTR.

Conclusions:

• Fenestration provides comparable symptom relief to resection for RCCs and superior headache resolution.
• Fenestration may reduce the risk of new endocrine deficits, particularly GH deficiency in smaller cysts.
• Recurrence rates are comparable between fenestration and GTR, suggesting fenestration is a viable, potentially safer alternative to resection.