[Endoscopic Endonasal Management of Rathke's Cleft Cysts: Surgical Strategies and Long-Term Outcomes]

Rathke's cleft cysts (RCCs) are non-neoplastic cystic lesions of the sellar region in which the primary pathological mechanism is the mass effect caused by cyst fluid accumulation. Although endoscopic endonasal surgery is the standard treatment for symptomatic RCCs, postoperative recurrence remains relatively frequent, and optimal surgical strategies remain debated. To improve long-term cyst control, we developed a mucosal coupling (MC) method, establishing a persistent drainage route from the cyst cavity to the sphenoid sinus using the sphenoid sinus mucosa. However, the MC method is not applicable in all cases, particularly in patients with intraoperative cerebrospinal fluid (CSF) leakage. We retrospectively analyzed 77 patients who had undergone endoscopic endonasal surgery for RCCs at our institution since 2010. Surgical strategies were selected based on preoperative magnetic resonance imaging findings and intraoperative assessment of CSF leakage, including conventional cyst fenestration with dural closure, the MC method, and cyst fenestration into the cistern through the opening of the diaphragma sellae. Surgical outcomes, recurrence, and complications were evaluated. The MC group demonstrated the lowest rate of symptomatic recurrence and required reoperation. Visual function improved in almost all patients, whereas postoperative endocrine deterioration occurred in a few patients. Postoperative CSF leakage remains a critical concern, emphasizing the importance of strict intraoperative evaluation and careful patient selection. Tailored surgical strategies focusing on preventing cyst fluid reaccumulation are essential for the optimal management of RCCs.