Long-term Surgical Outcomes and Recurrence Risk Stratification in Rathke's Cleft Cysts: Proposal of a Novel Scoring System

Abstract Rathke's cleft cysts (RCCs) are benign, nonneoplastic sellar lesions arising from Rathke's pouch remnants. Although surgery provides effective symptom relief, recurrence remains a major concern, and no validated tool exists to guide postoperative surveillance. To assess long-term surgical outcomes, identify recurrence predictors, and propose a novel recurrence risk score for RCCs. Patients with histopathologically confirmed RCCs who underwent surgery between January 2000 and December 2023 at a tertiary neurosurgical center were retrospectively analyzed. Clinical, radiological, and pathological variables were evaluated for recurrence prediction. A multivariate logistic regression model generated a seven-point risk score, validated through receiver operating characteristic analysis and Kaplan–Meier survival curves. Thirty-six patients (median age: 39.5 years; 55.6% female) were included, with a median follow-up of 100.5 months. Headache (72%) was the most frequent symptom, followed by visual and endocrine disturbances. Gross total resection was achieved in 75%. Recurrence occurred in four patients (11.1%) after a median of 118.5 months. Preoperative arginine vasopressin deficiency (AVP-D) independently predicted recurrence (OR: 8.84, p = 0.040), while subtotal excision, inflammation, and squamous metaplasia showed borderline significance. The composite seven-point score demonstrated excellent discrimination (AUC: 0.957, p = 0.003), with scores > 5 correlating with higher recurrence risk (log-rank p = 0.011). RCC recurrence is influenced by preoperative AVP-D, surgical extent, and cyst wall histopathology. The proposed risk score enables reliable recurrence stratification and may inform individualized postoperative surveillance strategies.