Symptom Resolution and Recurrence in Resection versus Fenestration for Rathke’s Cleft Cysts: A Propensity Score–Matched Analysis

Introduction: Rathke’s cleft cysts (RCCs) are benign sellar cysts which can require operative management for symptoms such as headache, visual deficits, or endocrine dysfunction. Resection and fenestration are the main surgical treatments for RCCs. However, data on long-term outcomes to guide patient selection remains limited.

Methods: A single-center retrospective review was conducted. Propensity score matching was done using age, sex, presenting symptoms, and cyst size. Kaplan–Meier curves and Cox proportional hazards regression were used to analyze recurrence.

Results: We analyzed 232 patients (131 resections, 101 fenestrations) with similar presenting symptom rates for headache (76 vs. 73%, p = 0.7), diabetes insipidus (6.2 vs. 8.1%, p = 0.6), hypopituitarism (0 vs. 1%, p = 0.4), and visual symptoms (44 vs. 42%, p = 0.8). However, patients undergoing fenestration had larger cysts (10 vs. 12 mm, p = 0.006, [Table 1]). We used propensity scores to match 194 patients ([Table 1]). Compared to resection, fenestration achieved similar rates of improvement among symptomatic patients for visual symptoms (64 vs. 67%, p = 0.9). However, there was a trend toward greater headache improvement with fenestration (40 vs. 56%, p = 0.074). Morbidities were also similar, including new transient or permanent postoperative diabetes insipidus (7.2 vs. 5.2%, p = 0.5) and new postoperative hypopituitarism (2.1 vs. 2.1%, p > 0.9). This propensity matched cohort was then divided into GTR, STR, and fenestration groups and compared to the original unmatched cohort ([Table 2]). The subgroup of STR patients was noted to have higher rates of visual symptoms at presentation (31 vs. 58 vs. 41%, p = 0.028) and less improvement in headache postoperatively among symptomatic patients (48 vs. 26 vs. 56%, p = 0.046, [Table 2]). There was also a trend towards larger cysts among the STR patients in the propensity matched cohort (10 vs. 13 vs. 12 mm, p = 0.2). Rates of cyst recurrence and recurrence free survival did not differ significantly among any of the groups ([Fig. 1A]–D). Multivariate Cox proportional hazards regression identified cyst size at diagnosis (HR: 1.07, [95% CI: 1.01–1.13], p = 0.018) and presence of postoperative residual cyst (HR: 6.61, [95% CI: 3.14–13.9], p < 0.001) as predictors of more rapid cyst recurrence. Fenestration (HR: 1, [95% CI: 0.44–2.26], p > 0.9) and STR (HR: 0.44, [95% CI: 0.17–1.18], p = 0.1, [Table 3]) were not associated with recurrence rate relative to GTR. Median censored time to recurrence for patients with residual cysts was 119 months while the median was not reached for patients without residual cyst (p < 0.001, [Fig. 1E]).

Conclusion: Cyst fenestration compared to resection achieves similar rates of improvement in visual symptoms and endocrine function in a propensity score–matched analysis, although patients with STR were less likely to experience improvement in headache. There were no differences in postop endocrine morbidities, rates of recurrence, or time to recurrence. Larger cyst size and presence of residual cyst both independently predict more rapid rate of cyst recurrence. These findings may guide surgeons in selecting operative approach by considering presenting symptoms, cyst size, and feasibility of complete resection.

Publication History

Article published online:
07 February 2025