Endoscopic Transsphenoidal Versus Transcranial Surgery for Sellar and Suprasellar Tumors: Seven-Year Comparative Outcomes in the Philippines

Introduction Sellar and suprasellar tumors constitute a significant proportion of intracranial neoplasms encountered in neurosurgical practice, with pituitary adenomas being the most common. The endoscopic transsphenoidal approach has become increasingly preferred due to its minimally invasive nature and enhanced visualization. However, comparative outcome data between transsphenoidal and transcranial approaches remain limited in low- and middle-income settings. This study aimed to compare clinical outcomes between these two surgical approaches in a tertiary government end-referral medical center in the Philippines. Methods A retrospective review of 129 consecutive adult patients who underwent surgical management between January 2019 and December 2025 was conducted. Patients were divided into endoscopic transsphenoidal (n = 109) and transcranial (n = 20) groups. Demographic data, comorbidities, pathology, tumor size, perioperative mortality, complications, visual improvement, and crude recurrence were analyzed using Chi-square/Fisher’s exact tests and Firth's penalized logistic regression. Results Pituitary adenomas predominated (77.5%; non-functioning 69.0%), followed by craniopharyngiomas (11.6%). Mean tumor diameter was 3.4 cm (range 1.8-5.5 cm), with 17.8% classified as giant (≥4.0 cm). Endoscopic transsphenoidal surgery was used in 84.5% of definitive resections (109/129). Perioperative mortality was 2.8% versus 15.0% (Fisher's exact p = 0.047), visual improvement 95.1% versus 75.0% (Fisher's exact p = 0.023), and major complications 6.4% versus 25.0% (Fisher's exact p = 0.058) in the transsphenoidal and transcranial groups, respectively. On Firth's penalized logistic regression (primary analysis due to low events-per-variable ratio of 1.2), a transcranial approach was associated with more than eightfold higher odds of mortality (adjusted OR 8.2, 95% CI 1.4-46.1; p = 0.018), whereas giant tumor size was associated with fourfold higher odds of death (adjusted OR 4.0, 95% CI 1.1-14.8; p = 0.035. Crude recurrence rates were 8.4% for adenomas, 26.7% for craniopharyngiomas, and 14.3% for meningioma/other lesions (10.9% overall). Conclusion The endoscopic transsphenoidal approach was associated with significantly lower perioperative mortality and superior visual outcomes compared to transcranial surgery. These findings indicate that its continued use as the primary surgical approach for most sellar and suprasellar tumors is still favorable even in resource-limited settings.