gms | German Medical Science

Objective: Rathke cleft cysts (RCC) may incidentally be discovered in patients complaining of headache, visual disturbance or hormonal imbalance. Controversies exist about the aim of surgery, whether pure cyst fenestration may increase the risk of cyst recurrence or cyst wall resection may count for a higher risk of pituitary dysfunction. We report our experience regarding the endoscopic management of RCCs.

Method: We retrospectively reviewed the data of 12 patients with symptomatic RCCs treated via an endoscopic endonasal approach at our department between 2004 and 2013. The average age was 57 years.

Results: Clinical symptoms presented by the patients included headache (5), visual field deficits (2) and endocrine dysfunction (8). The location of the RCC was intrasellar in 8 and with suprasellar extension in 4 cases. The mean cyst volume was 2,75 cm³. Full endoscopic endonasal surgery was performed in 8 patients whereas endoscope-assisted microsurgery was done in 4 patients. Complete removal of the cyst content was achieved in all patients under endoscopic control. Additional partial cyst wall resection was done in 4 cases only. An intraoperative CSF flow was observed in one patient. The other patients did not demonstrate any CSF flow after Valsalva maneuver either, but 3 of them developed a CSF leak after surgery. After surgery headache resolved in all patients, visual field deficits improved in 1/2 patients. Preoperative pituitary dysfunction improved in 2/8 patients but worsened in 1/8. Postoperatively 2/4 patients without prior hormonal changes developed either an immediate or late (after 5 months) pituitary dysfunction. Immediate hormonal changes occurred after additional cyst wall resection. The mean follow-up was 31.9 months (range 1-101 months). In two patients (16.7%) recurrent RCCs were diagnosed by MR imaging after 21 and 101 months. One case had to be operated on again after 40 month. In both cases a pure cyst fenestration was performed during initial surgery.

Conclusions: From our small experience we would postulate that pure fenestration of RCCs may increase the risk of cyst recurrence but minimizes the risk of pituitary dysfunction. Additionally, the absence of intraoperative CSF flow after removal of the cyst content does not provide security according to the appearance of CSF leaks. Therefore one has to balance for marsupialization the fenestrated cyst into the sphenoid sinus or covering the sella or sphenoid sinus after surgery.