Treatment Outcomes of Rathke's Cleft Cysts Managed with Marsupialization

Abstract

Objectives Rathke's cleft cysts (RCC) are benign cystic lesions of the sella resulting from incomplete obliteration of Rathke's cleft. Symptomatic lesions often require surgical decompression, which is often amenable to a transnasal, transsphenoidal (TNTS) approach. We report our experience with marsupialization of RCC and describe a novel technique to promote re-epithelization of the cyst cavity. Design Retrospective review. Setting Tertiary academic medical center. Participants Patients who underwent TNTS for RCC between 2007 and 2015. Main Outcome Measures Demographics, lesion characteristics, and reconstruction and treatment outcomes. Results In total, 52 patients were identified. The mean age was 41 ± 18 years. The mean RCC size was 13 ± 5 mm. Intraoperative cerebrospinal fluid (CSF) leak was encountered in 14 (27%) patients; all were repaired. There were six complications (12%) and no deaths. Mean follow-up was 20 ± 18 months, with five (10%) recurrences. RCC size was associated with intraoperative CSF leak (p = 0.04). In 12 patients, the marsupialized cyst cavity was lined with a free mucosal graft (FMG) to promote healing and re-epithelialization. Conclusions The TNTS approach is safe and effective in surgical decompression of RCC. Lining the exposed cyst cavity with an FMG is a simple intervention without added morbidity that may promote formation of an epithelialized tract. Level of Evidence Not applicable.

Keywords: Rathke's cleft cyst; free mucosal grafting; marsupialization.

Fig. 1

Marsupialization of Rathke's cleft cyst with free mucosal graft reconstruction. (A) After wide exposure of the sella is obtained, an inferiorly based dural incision is made sharply. (B) A transverse incision through the anterior pituitary capsule is made sharply. (C) The cyst cavity is entered and its contents are expressed through blunt dissection and gentle suctioning at the surface. (D) Solid components can be removed with suction or fine graspers. (E) Once the cyst is completely marsupialized, a free mucosal graft (blue coloring marks mucosal surface up) is placed into the inferior portion of the tract and additionally provides coverage of mucosa-denuded sellar bone. (F) At 8 weeks postoperatively, the marsupialized cavity has healed well and remucosalized.