Evolution of surgical management and functional outcomes of craniopharyngiomas: a systematic review and meta-analysis

Craniopharyngiomas (CPs) are rare benign epithelial tumors, whose management remains one of the most challenging feats in skull base surgery. Over recent decades, the evolution from transcranial microsurgical approaches (TCA) to extended endoscopic endonasal approaches (EEEA) has reshaped their management. This systematic review and meta-analysis aimed to elucidate the evolution of surgical treatment and define the functional outcomes of adult CP patients. A systematic review of the literature was carried out according to PRISMA 2020 guidelines, including papers from PubMed, Scopus, and Ovid databases. Meta-analyses of proportions were conducted using random-effects models (REML estimator), with heterogeneity assessed via the I² statistic. Meta-regression analyses explored the influence of publication year and geographic origin. Thirty-one retrospective studies encompassing 1,855 adult patients met the inclusion criteria. The mean age clustered between the fourth and fifth decades, with balanced sex distribution and follow-up durations ranging from 12 to 126 months. Preoperatively, anterior hypopituitarism occurred in 61.5%, diabetes insipidus (DI) in 19.7%, and obesity in 21.3% of patients. The majority of tumors were suprasellar-intraventricular (88.9%), with adamantinomatous histology predominating (72.2%). EEEA was the most used technique (57.4%), followed by TCA (35.6%). Gross total resection (GTR) rate was 68.1%, increasing to 76.2% in the EEEA subgroup. Meta-regression confirmed a significant temporal trend toward increased EEEA utilization (p = 0.040), while GTR rates remained stable over time. Postoperatively, hypopituitarism affected 79.6%, permanent DI 54.7%, and obesity 42.2% of patients; cognitive deficits were present in 10.6%. Recurrence occurred in 14.4% and all-cause mortality was 1.9%. The country of origin significantly influenced GTR outcomes (p = 0.004), reflecting institutional and technical variability. Egger’s test indicated no publication bias for EEEA rates (p = 0.683) but confirmed asymmetry for GTR (p < 0.001). The EEEA route is being increasingly favored for midline and suprasellar CPs, achieving robust rates of GTR (76.2%) for midline and suprasellar CPs, with higher visual improvement rates and acceptable morbidity in experienced hands. However, rates of postoperative endocrine and hypothalamic dysfunction remain high, highlighting the need for hypothalamic-sparing strategies and individualized surgical planning. Underreporting of hypothalamic invasion limits accurate interpretation of functional outcomes. Future prospective multicentric studies integrating molecular data, standardized neuropsychological assessment and clinical and surgical data reporting are essential to refine surgical decision-making and optimize quality of life for CP patients.