Endoscopic Endonasal Versus Supraorbital Approach For Tuberculum Sellae Meningioma: A Systematic Review and Meta-Analysis

Background: Tuberculum sellae meningioma (TSM) is a common meningioma subtype. The endoscopic endonasal approach (EEA) and supraorbital approach (SOA) are widely used minimally invasive techniques. This systematic review and meta-analysis compared outcomes between EEA and SOA for TSM management. Methods: Electronic databases were systematically searched for studies published within the past 10 years reporting EEA or SOA in TSM patients. Extracted data included patient and tumor characteristics, surgical approach, follow-up duration, and clinical outcomes. Meta-analysis of comparative studies assessed gross total resection (GTR), visual improvement, and complications. The study followed PRISMA guidelines and was registered in PROSPERO (CRD420251111461). Results: Of 901 screened studies, 20 met inclusion criteria, including 835 patients. Most patients were female (mean age 50 years) and presented with visual disturbances. Tumors managed with EEA were smaller and had shorter follow-up durations. Descriptive analysis showed lower GTR rates but higher visual improvement and complication rates with EEA compared to SOA. Meta-analysis revealed no significant differences between EEA and SOA for GTR (RR = 1.02; p = 0.85), visual improvement (RR = 1.25; p = 0.13), or complications (RR = 1.00; p = 1.00), though these findings reflect insufficient statistical power rather than clinical equivalence. Mortality and recurrence rates in the EEA group were 0.68% and 8.41%, respectively, while none were reported in the SOA group. Conclusion: Both EEA and SOA show no significant differences in tumor resection or visual recovery; however, this should be viewed as a lack of current evidence rather than proof of clinical equivalence. Surgical approach selection should be individualized based on tumor anatomy, surgical complexity, and the surgeon's expertise, with all outcome comparisons interpreted cautiously given the imbalance in sample size and follow-up duration between groups.