Objective To discuss the diagnosis and surgical treatment of symptomatic Rathke cleft cysts (RCCs). Methods Twenty-three symptomatic RCCs, who were verified by microsurgeries and pathological examination from Jan. 2001 to Oct. 2010, were retrospectively analyzed. Nine of them were males and fourteen of them were females. The main clinical manifestations included headache (65.2%), visual disturbance (34.8%) and pituitary dysfunctions (47.8%). The magnetic resonance imaging (MRI) showed 10 pure intrasellar lesions, 10 lesions of intrasellar with a suprasellar extension, and 3 pure suprasellar lesions. Sixteen cases were treated by transsphenoidal microsurgery and 7 were treated by craniotomy. The contents of the cysts were drained totally during the operation, and part of or the total cyst wall were safely moved and kept open. Results Postoperative follow-up period ranged from 14 months to 10 years. All the 8 patients were released from visual disturbance. Headache was improved in 13 of the 15 patients and pituitary dysfunction was improved in 7 of the 11 patients. Recurrence was noted in 1 patient. Conclusion Preoperative definite diagnosis for the symptomatic RCCs is difficult due to a variety of clinical manifestations and MRI signals. Most of the lesions can be treated via transsphenoidal approach. Transcranial approach is necessary for the pure suprasellar RCCs. Microsurgery is an effective strategy for the treatment of symptomatic RCCs, because it can safely relieve the symptoms and make definite diagnosis.