Background. Craniopharyngioma is a WHO grade I epithelial tumor arising from Rathke's pouch remnants. Despite its histologically benign nature, it poses formidable surgical challenges owing to its proximity to the optic apparatus, hypothalamus, pituitary stalk, and major cerebrovascular structures. Both the extended endoscopic endonasal transplanum-transtuberculum approach and the endoscopic supraorbital eyebrow keyhole craniotomy represent established minimally invasive techniques; however, direct comparative institutional evidence from lower-middle-income settings remains limited. Methods. We conducted a single-center retrospective cohort study at Mayo Hospital, Lahore, Pakistan, reviewing consecutive surgical records from June 2007 to September 2022. Of 67 patients assessed, 60 met eligibility criteria: 30 underwent endoscopic endonasal surgery (Group A) and 30 underwent endoscopic supraorbital keyhole craniotomy (Group B). Inclusion required age 5–65 years, radiologically confirmed craniopharyngioma, preoperative visual impairment, and primary surgical treatment at our institution. Co-primary outcomes were gross-total resection (GTR) on 48-hour postoperative MRI and visual improvement at 3 months. Secondary outcomes—including cerebrospinal fluid (CSF) leak, new endocrine deficits, and recurrence at last follow-up were reported descriptively. Between-group differences in primary outcomes were assessed by the chi-square test (α = 0.05), and relative risks (RR) with 95% confidence intervals (CI) were calculated. Results. Baseline characteristics were broadly comparable, although tumor location differed by design: suprasellar/intrasellar lesions predominated in Group A (73.3% vs. 33.3%), while retrochiasmatic or intraventricular tumors were more frequent in Group B (40.0% vs. 13.3%). GTR was achieved in 83.3% of Group A versus 60.0% of Group B (p = 0.045; RR 1.39, 95% CI 1.00–1.93). Visual improvement occurred in 86.7% versus 63.3%, respectively (p = 0.037; RR 1.37, 95% CI 1.03–1.82). CSF leak rates were numerically higher in Group A (13.3% vs. 3.3%), while endocrine outcomes and recurrence rates did not differ significantly between groups. Median follow-up was 38 and 41 months for Groups A and B, respectively. Conclusions. In this selected cohort, the endoscopic endonasal approach was associated with higher rates of GTR and visual improvement compared with the endoscopic supraorbital keyhole approach. These findings reflect, in part, preferential allocation of midline suprasellar tumors to the endonasal route and should not be interpreted as evidence of absolute superiority. Both approaches remain complementary, and surgical strategy should be individualized based on tumor morphology, hypothalamic involvement, and surgeon expertise. Prospective multicenter studies with standardized allocation, comprehensive complication data, and validated quality-of-life endpoints are needed to confirm these observations.
Phuyal et al. (Mon,) studied this question.