Comparative surgical outcomes of pterional, supraorbital, and endoscopic endonasal approaches for tuberculum sellae meningiomas: a systematic review and network meta-analysis

BACKGROUND: The optimal surgical corridor for tuberculum sellae meningiomas (TSMs) remains a subject of ongoing debate. While the pterional (PT) approach is the traditional gold standard, the endoscopic endonasal approach (EEA) and supraorbital (SO) keyhole approach have emerged as viable alternatives. OBJECTIVE: To comparatively evaluate the surgical outcomes and complication profiles of the PT, SO, and EEA techniques for the management of TSMs. METHODS: A systematic literature search was conducted across PubMed, Embase, Scopus, Web of Science, and Cochrane databases through March 2026. Frequentist random-effects network meta-analysis was performed to compare gross total resection (GTR), visual improvement, and complications. Treatment rankings were estimated using Surface Under the Cumulative Ranking Curve (SUCRA) scores. RESULTS: Six retrospective comparative studies involving 205 patients were included. Network meta-analysis showed no statistically significant differences between approaches for gross total resection (PT vs. EEA: RR 1.21, 95% CI 0.85-1.73; SO vs. EEA: RR 1.04, 95% CI 0.86-1.24). SUCRA rankings suggested only exploratory numerical patterns, with PT ranking highest for GTR and SO showing a non-significant trend for visual improvement compared with EEA (RR 1.30, 95% CI 0.95-1.76). These rankings were not supported by statistically significant pairwise differences and should be interpreted cautiously because of sparse evidence, retrospective study designs, and wide confidence or prediction intervals. Secondary outcomes, including cerebrospinal fluid leak, diabetes insipidus, and tumor recurrence, were imprecisely estimated and broadly comparable across approaches. CONCLUSION: Available retrospective comparative evidence suggests that pterional, supraorbital, and endoscopic endonasal approaches may provide broadly comparable outcomes for TSMs, but the certainty of evidence is limited. No approach demonstrated statistically significant superiority. Surgical corridor selection should remain individualized according to tumor anatomy, including lateral extension, vascular encasement, and optic canal involvement, as well as institutional expertise and surgeon experience.