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 with resection or fenestration for symptoms such as headache, visual deficits, or endocrine dysfunction. However, data on long-term outcomes to guide patient selection remains limited.

Methods: Single-center retrospective review. Propensity score matching was done using age, sex, presenting symptoms, and cyst size. Recurrence was analyzed with multivariate Cox Proportional Hazards regression.

Results: We analyzed 275 patients (138 resection, 137 fenestration) with similar presenting symptom rates for headache (76% vs 73%, p=0.6), diabetes insipidus (7.5% vs 7.6%, p>0.9), hypopituitarism (22% vs 24%, p=0.7), and visual symptoms (42% vs 39%, p=0.6). Patients undergoing fenestration had larger cysts (11.4mm vs 12.9mm, p=0.035). We used propensity scores to match 234 patients who were then divided into GTR, STR, and fenestration groups. Among symptomatic patients, headache improvement was greatest with fenestration (46% vs 34% vs 60%, p=0.028) with similar improvements in visual symptoms (71% vs 65% vs 64%, p>0.9). New postoperative hypopituitarism was more common among patients with GTR (20% vs 4.9% vs 11%, p=0.051). Postoperative diabetes insipidus rates did not differ (9.6% vs 4.9% vs 13%, p=0.4). Postoperative residual cyst (18% vs 64% vs 25%, p< 0.001) and recurrence (15% vs 31% vs 18%, p=0.1) were most common in patients with STR. Multivariate analysis identified residual cyst (HR 7.84, [95% CI 2.59-23.8], p< 0.001; 98 months vs median not reached, p< 0.001) as a predictor of faster recurrence with a trend for larger cysts (HR 1.08, [95% CI 0.99-1.18], p=0.079).

Conclusion : Cyst fenestration compared to resection achieves similar improvements in visual symptoms and endocrine function, but greater headache resolution. GTR is associated with more postoperative hypopituitarism while STR trends towards higher recurrence rates. Postoperative residual cyst predicts more rapid recurrence. These findings may guide operative strategy by considering presenting symptoms, cyst size, and feasibility of complete resection.