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Meta-Analysis
. 2025 Apr 14;28(3):49.
doi: 10.1007/s11102-025-01521-4.

Impact of sella floor reconstruction on Rathke Cleft Cyst recurrence: a systematic review and meta-analysis

Ryan Beerling Dolovac  1 , James King  2   3 , Christopher Ovenden  4   5 , Jeremy Kam  6   7 , Yi Yuen Wang  8   3 , Tony Goldschlager  6   7 , Mendel Castle-Kirszbaum  9   10
Affiliations
Meta-Analysis

Impact of sella floor reconstruction on Rathke Cleft Cyst recurrence: a systematic review and meta-analysis

Ryan Beerling Dolovac et al. Pituitary. .

Abstract

Background: The optimal surgical technique for managing Rathke's Cleft Cyst (RCC) remains unclear. Leaving the sellar defect open (marsupialisation) after transsphenoidal surgery facilitates ongoing drainage of cyst contents, but cannot be performed in the setting of an intraoperative cerebrospinal fluid (CSF) leak. The effects of intraoperative CSF leaks and sellar floor reconstruction on RCC recurrence require further investigation.

Methods: A systematic literature search was conducted for studies reporting RCC recurrence following transsphenoidal surgery, with data on intraoperative CSF leak rates and skull base reconstruction. Studies were classified based on surgical technique: cyst wall resection vs. fenestration, and open (no reconstruction) vs. closed (reconstructed) sellar floor.

Results: Nineteen studies, comprising 1,076 patients, were included. The overall radiological RCC recurrence rate was 19.8% over a mean follow-up of 50.4 months. The recurrence rate in closed sella surgeries was significantly higher (32.1%) than in open sellar cases (14.0%) (OR 2.28, 95% CI: 1.41-3.67, p < 0.05). Intraoperative CSF leak occurred in 29.1% of cases. Patients with CSF leaks had a higher recurrence rate (23.4% vs. 12.9%), though meta-analysis demonstrated only a non-significant trend (OR 1.67, 95% CI: 0.95-2.96). Subgroup analysis revealed that intraoperative CSF leaks were significantly associated with increased recurrence after fenestration (38.5% vs. 18.4%, p = 0.03), and cyst wall resection (21.7% vs. 7.8%, p = 0.004). In the setting of an intraoperative CSF leak, there was a trend for lower recurrence when cyst wall resection was attempted (21.7% vs. 38.5%, p = 0.09).

Conclusion: Patients undergoing transsphenoidal surgery for RCC experience high rates of postoperative radiological recurrence. Cyst fenestration while maintaining an open sellar floor (marsupialisation into the sphenoid sinus) is associated with a significantly lower risk of recurrence at over 4 years follow-up. Intraoperative CSF leaks were less strongly associated with cyst recurrence, suggesting that watertight reconstruction, rather than the leak itself, is the primary driver of reaccumulation. When a closed sella is necessitated by intraoperative CSF leak, the addition of cyst wall resection may be associated with a lower rate of recurrence than fenestration alone but must be weighed against a higher risk of AVP-deficiency.

Keywords: Cyst; Flap; Pituitary; Rathke; Reconstruction; Recurrence.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not required. Consent for publication: Not required. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Forrest plot depicting meta-analysis of radiological recurrence in open vs. closed sella
Fig. 2
Fig. 2
Forrest plot depicting meta-analysis of radiological recurrence by intraoperative CSF leak status
Fig. 3
Fig. 3
A proposed algorithm for RCC management
See this image and copyright information in PMC

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