Resection versus fenestration for Rathke’s cleft cysts: a propensity score–matched analysis of long-term outcomes

OBJECTIVE: Rathke's cleft cysts (RCCs) are benign sellar lesions that may require surgical intervention for visual field deficits, endocrinopathy, or headache. Cyst fenestration and cyst wall resection are both established surgical treatments. However, there is ongoing debate regarding the value of the aggressive approach of removing the cyst wall to prevent recurrence, weighed against risking additional endocrine complications. This study compares long-term outcomes in consecutive patients with RCCs at a single institution according to surgical strategy. METHODS: The authors performed a single-center retrospective analysis of patients undergoing surgical management of pathology-confirmed RCCs using resection (characterized as gross-total [GTR] or subtotal [STR] resection) or fenestration from 2000 to 2023. Propensity scores generated from cyst characteristics were used to match patients who underwent resection or fenestration. Presenting and postoperative symptom outcomes by approach were compared. Kaplan-Meier curves and multivariate Cox proportional hazards regression were used to analyze recurrence. RESULTS: Two hundred seventy-eight patients were included, with larger cysts noted in patients undergoing fenestration (14.0 mm) compared to resection (11.5 mm; p < 0.001). After matching, the cohort contained 242 patients, and improvement rates in visual and endocrine symptoms were similar between fenestration and resection. Patients who received resection (regardless of extent) had significantly lower rates of headache resolution (43% with GTR vs 34% with STR vs 59% with fenestration, p = 0.037), and when comparing all hormonal axes, higher rates of new growth hormone (GH) deficiency (10% with GTR vs 16% with STR vs 3.2% with fenestration, p = 0.025) compared to patients with fenestration. Further stratification of cysts ≤ versus > 15 mm revealed lower rates of new postoperative GH deficiency in smaller cysts undergoing fenestration (11% with GTR vs 14% with STR vs 2.4% with fenestration, p = 0.043). While fenestration versus resection did not impact recurrence, STR was associated with more rapid cyst recurrence by Kaplan-Meier analysis. A postoperative residual cyst was the strongest predictor of recurrence in multivariate Cox proportional hazards regression (hazard ratio 4.01, 95% CI 2.41-6.65; p < 0.001). CONCLUSIONS: Compared to resection, fenestration achieves similar improvement rates in presenting visual and endocrine symptoms in patients with RCCs, and greater postoperative headache resolution. It may also reduce the risk of new postoperative endocrine complications, particularly GH deficiency in cysts ≤ 15 mm. Recurrence rates and recurrence-free survival among patients receiving fenestration are also comparable to those who receive GTR. These findings may guide surgical decision-making by supporting fenestration as a safer alternative to resection in certain cases.