Comparative outcomes of transcranial craniotomy and endoscopic endonasal surgery for craniopharyngioma: a single-center retrospective cohort study.

Background: The optimal surgical corridor for craniopharyngioma remains debated. Endoscopic endonasal approach (EEA) offers a direct midline trajectory to the sellar/suprasellar region, whereas transcranial approaches remain important for lesions with complex extension. We compared perioperative and follow-up outcomes between EEA and transcranial craniotomy in a single-center cohort, emphasizing detailed preoperative anatomical classification and domain-specific functional outcomes. Methods: We performed a retrospective cohort study of consecutive patients undergoing primary craniopharyngioma resection at the Affiliated Hospital of Xuzhou Medical University (January 2019-December 2024). Patients were grouped by surgical corridor used in routine care: transcranial craniotomy (TCA, n=33) or EEA (n=34). Preoperative MRI was reviewed for topography, cystic proportion, calcification, lateral extension beyond the internal carotid artery (ICA), vascular encasement, QST type, Kassam type, and Puget grade. Gross total resection (GTR) was defined as no residual enhancing tumor on MRI within 72 hours. Outcomes included extent of resection, length of stay, complications, axis-specific endocrine outcomes and replacement burden at 6 months, objective visual outcomes at 3 months, postoperative radiotherapy, and recurrence/progression at last follow-up. Results: Baseline demographic, anatomical, and endocrine characteristics were comparable between groups. EEA achieved a higher GTR rate (82.4% vs. 45.5%, p=0.002) and shorter hospital stay (16.19 ± 3.97 vs. 18.76 ± 4.23 days, p=0.019). At 6 months, headache/ICP-related symptoms improved in 90.9% of EEA patients versus 76.5% of TCA patients (p=0.047). Objective postoperative 3-month best-corrected visual acuity (BCVA, logMAR) was better after EEA (0.30 [0.12, 0.45] vs. 0.42 [0.22, 0.62], p=0.041). EEA was associated with lower rates of electrolyte imbalance (17.6% vs. 42.4%, p=0.021), transient diabetes insipidus (DI) (20.6% vs. 45.5%, p=0.028), persistent DI (≥3 months) (14.7% vs. 30.3%, p=0.048), and new hypopituitarism (any axis) (41.2% vs. 69.7%, p=0.022). The pituitary stalk was anatomically preserved more frequently in EEA cases (67.6% vs. 48.5%, p=0.042). Median follow-up was 35-37 months; recurrence/progression at last follow-up occurred in 8.8% of EEA patients versus 21.2% of TCA patients (p=0.047). Conclusion: In this retrospective cohort with detailed anatomical reclassification, EEA was associated with higher GTR, shorter hospitalization, and fewer short-term endocrine/electrolyte complications, with comparable overall safety. Because corridor selection is anatomy-driven and this unadjusted observational comparison is susceptible to confounding by indication, these findings should be interpreted as comparative outcomes among selected patients rather than causal evidence of superiority.