Microscopic vs. exoscopic transsphenoidal surgery for rathke's cleft cyst- a retrospective single center study.

BACKGROUND

Microscopic (MTS) or endoscopic transsphenoidal surgeries (ETS) are two main well established approaches for the management of sellar pathologies in contemporary established approaches for the management of sellar pathologies in contemporary neurosurgical practice. Exoscopic transsphenoidal surgery (ExTS), which employs a 4K 3D camera system (Orbeye, Olympus), has recently emerged as a promising alternative; however, its role in the management of Rathke’s cleft cysts (RCC) remains unclear. This study aimed to evaluate the surgical characteristics and clinical outcomes of ExTS in patients with RCC and to compare these results with those achieved using the more widely established microscopic transsphenoidal surgery (MTS) technique.

METHODS

We performed a retrospective analysis of electronic medical records of all transsphenoidal operations conducted between July 2013 and May 2022 at the University Medical Center Hamburg-Eppendorf. 125 patients with RCC after a defined type of transsphenoidal surgery were included.

RESULTS

Mean operative duration was similar between groups (78.5 ± 21.7 min vs. 73.1 ± 26.7 min, p = 0.20). Complication and recurrence rates did not differ significantly between MTS and ExTS (16.7% vs. 9.7%; p = 0.54). Across learning phases, ExTS showed a greater reduction in operative time (85.5 → 59.8 min; p = 0.047) than MTS (98.2 → 84.6 min; p = 0.128). In the mixed-effects model adjusting for clinical covariates and inter-surgeon variability, surgical technique (ExTS vs. MTS; p = 0.021), age (p = 0.005), previous surgery (p = 0.008), suprasellar cyst location (p = 0.031), and drainage (p = 0.006) were significant predictors of operative duration. A significant Experience × ExTS interaction (p = 0.005) indicated a more pronounced experience-dependent reduction in operative duration for ExTS compared with MTS.

CONCLUSION

ExTS using a 4K 3D system demonstrated safety and efficacy comparable to the MTS. After adjustment for clinical covariates and inter-surgeon variability, ExTS remained an independent predictor of shorter operative duration and demonstrated a more pronounced independent predictor of shorter operative duration and demonstrated a more pronounced experience-dependent reduction in operative duration for ExTS compared with MTS. These findings support ExTS as a safe and time-efficient alternative for managing RCC. Nevertheless, prospective multicenter studies with long-term follow-up are required to validate these results and further delineate the role of exoscopic system.