High recurrence of rathke's cleft cysts with anterior-Inferior pituitary displacement despite standard surgical approaches.

Abstract

Purpose: Although endonasal endoscopic surgery (EES) is widely used to treat symptomatic Rathke's cleft cysts (RCCs), the optimal surgical strategy remains unclear. We previously proposed that the anatomical relationship between RCCs and the anterior pituitary lobe may predict recurrence. This study aimed to evaluate clinical characteristics and long-term outcomes based on anatomical classification and to assess the impact of surgical method (marsupialization vs. reconstruction) within each subtype.

Methods: We retrospectively analyzed 40 patients who underwent EES for symptomatic RCCs between 2008 and 2024. RCCs were classified into four types based on displacement: type 1 (anterior-superior), type 2 (anterior-inferior), type 3 (posterior-superior), and type 4 (posterior-inferior). Clinical, imaging, and surgical outcomes were compared across subtypes.

Results: he mean follow-up duration was 112 ± 53.2 months. Recurrence occurred in 16 patients (40.0%), and 6 (15.0%) patients required reoperation. Type 2 was independently associated with a higher recurrence rate (p = 0.019), more frequent preoperative visual disturbances (p = 0.0059), and lower T1-weighted signal intensity (p = 0.027). There was no significant difference in the recurrence rate between the surgical methods within each subtype.

Conclusion: The anterior-inferior subtype is more likely to recur regardless of the surgical method. The identification of high-risk subtypes may support the use of tailored strategies, including drainage-preserving techniques, to improve long-term outcomes.