Standard anterior temporal lobectomy using a retractorless technique in patients with drug-resistant mesial temporal lobe epilepsy: long-term seizure outcomes and predictors of postoperative seizure freedom

Background: Fixed brain retractors risk focal ischemia and cortical injury. Although retractorless dynamic retraction is established in skull base surgery, its role in epilepsy surgery remains poorly characterized. Objective: To evaluate long-term seizure outcomes, safety, and reliability of retractorless standard anterior temporal lobectomy (ATL) in drug-resistant mesial temporal lobe epilepsy (MTLE), and identify predictors of seizure freedom. Methods: We retrospectively analyzed 42 patients who underwent retractorless standard ATL for drug-resistant MTLE. Dynamic retraction used bipolar forceps and pressure-controlled suction. The primary outcome was seizure freedom (Engel Class Ia) at minimum 24-month follow-up; secondary outcomes were complications and resection adequacy on postoperative magnetic resonance imaging (MRI). Predictors were identified using multivariable logistic regression and Cox proportional hazards models. Results: At a mean follow-up of 66.3 months, 69% of patients achieved complete seizure freedom (Engel Class Ia), and 83.3% achieved freedom from disabling seizures (Engel Class I). Postoperative MRI confirmed adequate resection in 95.2% of cases. Complications were uncommon and unrelated to retraction injury. Low preoperative seizure frequency (< 3 seizures/week) was the sole independent predictor of seizure freedom (odds ratio, 24.21; P = 0.026), while higher frequency (≥ 3 seizures/week) was associated with increased recurrence risk (hazard ratio, 7.34; P = 0.042). Conclusion: Retractorless standard ATL is safe and effective for drug-resistant MTLE, achieving long-term seizure control while minimizing retraction-associated risks. Preoperative seizure burden was the dominant prognostic marker, supporting early surgical intervention.