Efficacy and Safety of Endoscopic Third Ventriculostomy Compared with Ventriculoperitoneal Shunting in Pediatric Post-Inflammatory Hydrocephalus: A Systematic Review and Meta-Analysis

Abstract Background Ventriculoperitoneal shunting (VPS) remains the standard treatment for pediatric post-inflammatory hydrocephalus because it provides reliable cerebrospinal fluid diversion, but it is associated with infection, treatment failure, repeated revisions, and lifelong device dependency. Endoscopic third ventriculostomy (ETV) offers a shunt-independent alternative that may reduce long-term device-related complications, although its comparative efficacy and safety remain uncertain. Methods Nine databases were searched from inception to 28 February 2026 under a registered PROSPERO protocol (CRD420261382819). Random-effects models were used for direct comparative meta-analyses, with supplementary single-arm syntheses to estimate pooled procedure-specific event rates. Results Of 3,995 records identified and 2,092 screened after deduplication, 22 studies comprising 13,778 children were included. In comparative analyses, ETV and VPS showed no statistically significant difference in treatment success (RR 0.98, 95% CI 0.73–1.31), mortality (RR 1.24, 95% CI 0.68–2.28), or overall complications (RR 2.09, 95% CI 0.17–25.27). In single-arm analyses, the pooled success rate was 51% for ETV and 63% for VPS. The pooled mortality rate was 7% for ETV and 4% for VPS. Revision rates were 45% and 39%, respectively, while overall complication rates were 25% for ETV and 26% for VPS. Infection rates were 8% for ETV and 13% for VPS. Conclusions Current evidence does not show a clear superiority of ETV or VPS for pediatric post-inflammatory hydrocephalus. ETV may show numerically lower infection and mortality, but this should be interpreted cautiously given marked heterogeneity and limited head-to-head data.