Symptomatic Rathke cleft cysts: extent of resection and surgical complications

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Rathke cleft cysts (RCCs) are benign masses arising from the embryological Rathke pouch, and are commonly treated by transsphenoidal surgery. The authors retrospectively compared RCC extent of resection—either gross-total resection (GTR) or decompression—to the primary outcome measure, which was recurrences resulting in repeat surgery, and the secondary outcome measure, which was complications.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Seventy-four patients presenting to the neurosurgical department with RCC were analyzed retrospectively. Sixty-eight patients had a total of 78 surgical procedures, with the diagnosis of RCC confirmed by histological investigation; of these, 61 patients had adequate operative notes for the authors to evaluate extent of resection. Groups were separated into GTR (32 patients) or decompression (subtotal resection or fenestration into the sphenoid sinus; 29 patients) based on operative notes and postoperative imaging. The mean follow-up duration was 60.5 ± 72.1 months (the mean is expressed ± SD throughout).</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The average age at the time of the initial surgery was 42.8 ± 17.4 years, and 70% of patients were female. The mean cyst diameter preoperatively was 16.9 ± 17.8 mm. Eight patients had repeat surgery, our primary outcome measure; 3 repeat operations occurred in the GTR group, and 5 in the decompression group. There was no significant difference in recurrence when comparing groups (GTR 9%, decompression 17%; p = 0.36). There were no major complications; however, analysis of postoperative minor complications revealed that 11 (34%) GTRs resulted in surgical complications, whereas the decompression cohort accounted for only 3 complications (10%) (p = 0.03), with diabetes insipidus (6) and CSF leaks (5) being the most common. Gross-total resection also resulted in an increase in postoperative hyperprolactinemia compared with decompression (p = 0.03).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>It appears that RCCs require repeat surgery in 13% of cases, and attempted GTR does not appear to reduce the overall rate of recurrence. However, more aggressive resections are associated with more complications in this series.</jats:p></jats:sec>

Individualized surgical strategies for Rathke cleft cyst based on cyst location

“…Aho et al 1 reviewed 118 cases of RCC, and concluded that there was no difference in recurrence rate between radical resection and decompression. Higgins et al 13 also found no significant advantage for GTR with respect to recurrence rate but did find that it was associated with more complications than less aggressive surgery. In addition, we found a possible association between a higher recurrence rate and graft packing for CSF leak, as some authors have mentioned.…”

“…All these results indicated that radical surgery may carry a greater risk of postoperative morbidity, as reported by other authors. 1,13,24,34 Radiological recurrence occurred in 13% of the total population in our series over a median follow-up period of 46 months. This rate is consistent with prior studies.…”

“…However, the range of recurrence rates in previous reports is quite large (0%-42%). 1,8,11,13,15,[23][24][25]28,[34][35][36]47,53 Several factors, including sample size, surgical modalities, duration of follow-up, and definitions of recurrence, may account for the variation. For example, the radiological recurrence rate in our series was 13%, while the symptomatic recurrence rate was 8%.…”

“…5,11,13,15,23,24,28,29,[34][35][36] Potts et al 35 retrospectively reviewed a total of 151 RCCs and reported 19 cases (13%) of suprasellar lesions. They compared the presentations, surgical outcomes, and pathology of lesions with different location, but did not evaluate different surgical approaches according to cyst location and extent of resection.…”

“…13,24,27,28,31,34,35,50 Even in the setting of RCCs with suprasellar location, multiple cases of extended transsphenoidal approaches for cyst removal have also been reported. 28,34,35 Other minimally invasive approaches, such as the supraorbital keyhole craniotomy, although being increasingly used to access sellar or parasellar tumors, have not yet been employed in removing RCCs.…”