Background: Craniopharyngiomas are histologically benign but clinically aggressive epithelial tumors that pose significant surgical challenges due to their proximity to the hypothalamic–pituitary axis. While traditional transcranial approaches are well-established, the endoscopic endonasal transplanum–transtuberculum approach (EETTA) has emerged as a specialized corridor offering direct midline access. This systematic review evaluates the surgical efficacy, functional outcomes, and complication profiles of the EETTA over two decades of clinical evolution. Methods: Following PRISMA guidelines, a systematic search was conducted across five databases. Eligible studies included patients of all ages undergoing EETTA for craniopharyngioma. Data on the extent of resection (EOR), visual and endocrine outcomes, and CSF leak rates were extracted. Quality was assessed using NIH/JBI tools, and evidence was graded via AANS/CNS criteria. Results: Fifty-one studies (677 patients) were included. The cohort had a mean age of 43.4 years and predominantly suprasellar tumors (mean diameter 2.9–4.0 cm). Gross total resection (GTR) was achieved in 66.4% of cases (364/548). Postoperative visual improvement was reported in 79.8% of patients, while 7.1% experienced deterioration. Endocrine morbidity remained significant, with 120 patients developing new-onset diabetes insipidus and 105 developing new anterior pituitary deficits. The pooled CSF leak rate was 9.2%, with contemporary series frequently reporting 0% due to advanced multilayer reconstruction with nasoseptal flaps. The pooled recurrence rate was 7.8% over a mean follow-up of 37.4 months. Conclusions: The EETTA is a safe and effective primary strategy for suprasellar and retrochiasmatic craniopharyngiomas, offering more favorable visual outcomes and resection rates in this specific cohort. While endocrine dysfunction remains a pervasive challenge inherent to the tumor’s location, technical refinements in skull base reconstruction have successfully addressed historical concerns regarding CSF leaks. These findings support the use of the EETTA at high-volume centers with multidisciplinary expertise.
Alomari et al. (2026) studied this question.