Surgical management of symptomatic recurrent Rathke's cleft cysts: A systematic review and individual-participant data meta-analysis

The optimal management of symptomatic recurrent Rathke's cleft cysts (RCCs) is unclear. Here, we compared the outcomes of various surgical approaches for symptomatic recurrent RCCs. PubMed and Embase were systematically reviewed for studies that reported individual-participant data on outcomes after surgical treatment for symptomatic recurrent RCCs presenting with headache and/or visual field defect. The primary outcome was symptomatic recurrence, and the secondary outcome was postoperative complications. Subgroup analyses were performed based on the number of recurrences, duration since initial surgery, previous treatment, and symptoms of recurrence. Of the 713 studies screened, 14 studies (30 recurrences in 24 patients) were included in the metaanalysis. Cyst wall resection was the most common treatment (n = 17, 56.7 %), followed by drainage with intrasellar stent insertion (n = 7, 23.3 %) and resection with intracystic bleomycin (n = 6, 20.0 %). Most of the cases were first recurrences (56.7 %, n = 17). The mean (SD) duration between the initial treatment and onset of symptomatic recurrence was 3.0 (3.6) years. Over a median [IQR] follow-up period of 1.2 [0.4, 2.5] years, patients who underwent cyst wall resection had a significantly higher incidence of symptomatic recurrence at 58.8 %, compared to a 0 % symptomatic recurrence rate in patients treated with drainage and intrasellar stent insertion or resection with intracystic bleomycin (p = 0.014). Patients who underwent cyst wall resection also had the highest risk of symptomatic recurrence on subgroup analysis, though this was statistically significant only among patients who underwent cyst wall resection as their preceding treatment (p = 0.021). There were no significant differences in postoperative complication rates between the treatment arms. In conclusion, for patients with symptomatic recurrent RCCs presenting with headache and/or visual field defects, drainage with intrasellar stent insertion and intracystic bleomycin may be superior to cyst wall resection alone. This approach may reduce the risk of another symptomatic recurrence within one year.