Objective <p>Direct surgical resection may be the only choice for solid or predominantly solid third ventricle craniopharyngiomas (TVCs) complicated with hydrocephalus. Despite the increased use of the extended endoscopic endonasal approach (EEEA), the viewpoint that these tumors are unsuitable for endonasal resection remains prevailing. This paper presents the largest case series assessing the surgical outcomes of EEEA for solid or predominantly solid TVCs complicated by hydrocephalus.</p> Methods <p>We retrospectively analyzed the data of 27 patients newly diagnosed with solid or predominantly solid TVCs complicated with hydrocephalus treated by EEEA.</p> Results <p>Gross total resection (GTR) was achieved in 88.9% of 27 patients. The rate of hydrocephalus relief was 100%, with an average Evans’ index decrease of 0.05 and a simplified callosal angle increase of 15.8°. The mean Mini-Mental State Examination score improved significantly in the strictly TVC group after surgery (<i>p</i> = 0.03) but not in the infundibulo-tuberal TVC group (<i>p</i> = 0.61). Postoperative visual worsening occurred in 11.1% of patients. New-onset hypopituitarism was observed in 62.9% of patients. Permanent diabetes insipidus occurred in 63.0% of patients. New-onset obesity was noted in 17.4%. During a mean follow-up of 38.9 months (range 12.9–67.9 months), tumor recurrence and mortality rates were 11.1% and 0%, respectively.</p> Conclusions <p>The EEEA could be a safe and effective choice for solid or predominantly solid TVCs complicated with obstructive hydrocephalus, offering a higher rate of GTR and a lower rate of newly developed postoperative hydrocephalus. Intraoperative VEP monitoring may be necessary to minimize the risk of postoperative visual deterioration.</p>