Long-term endocrine trajectories and reoperation risk after surgery for Rathke’s cleft cysts: a single-center cohort study of 177 patients

PURPOSE: To characterise endocrine trajectories after surgery for Rathke's cleft cysts (RCCs) and identify factors associated with pituitary hormonal dysfunction and reoperation. METHODS: Retrospective single-centre cohort of 177 patients undergoing RCC surgery (2004-2023). Preoperative MRI volumetry, cyst location, histopathology, and longitudinal endocrine assessments were analysed. Early postoperative MRI defined residual cyst status. Reoperation-free survival was assessed by Kaplan-Meier and multivariable Cox regression. RESULTS: Patients were 67.8% women (mean age 44.8 ± 17.0 years); median follow-up was 38.5 months. Preoperatively, 50.3% had anterior pituitary dysfunction, 33.3% hyperprolactinaemia, and 9.0% arginine vasopressin deficiency (AVP-D). Larger cyst volume was independently associated with hyperprolactinaemia and gonadal axis dysfunction, whereas age and sex showed axis-specific associations. Cyst location had limited explanatory value. An inflammatory-metaplastic cyst-wall phenotype was associated with more frequent pituitary hormonal dysfunction at presentation. Postoperatively, hyperprolactinaemia resolved in 78.0% of affected patients. AVP-D increased to 24.3% early after surgery and persisted in 22.0% at last follow-up. Gross total resection was achieved in 82.9%, and reoperation occurred in 15.8%. In landmark analysis, residual cyst on early postoperative MRI remained strongly associated with subsequent reoperation after adjustment for age, sex, cyst volume, and location. CONCLUSION: Larger cyst volume and an inflammatory-metaplastic cyst-wall phenotype were associated with more frequent pituitary hormonal dysfunction at diagnosis. Most clinically relevant net endocrine changes occurred within the first three postoperative months, supporting standardised reassessment at this time point as a pragmatic early follow-up milestone. Early postoperative MRI residual was strongly associated with reoperation, supporting a function-preserving surgical strategy and risk-adapted follow-up.