<p>To compare surgical outcomes between endoscopic and microscopic transsphenoidal pituitary surgery using international comparative evidence and an institutional cohort. A PRISMA-based systematic review and meta-analysis of comparative transsphenoidal pituitary surgery studies was performed. Gross total resection was the primary endpoint. Secondary outcomes included operative time, intraoperative blood loss, cerebrospinal fluid leak, epistaxis, meningitis, diabetes insipidus, SIADH, and visual outcomes. Fixed- and random-effects models were applied. Fifty-six comparative studies including 26,295 patients from 23 countries were analyzed (13,575 endoscopic, 12,534 microscopic), supplemented by an institutional cohort of 142 patients. Endoscopic surgery was associated with higher gross total resection rates (random-effects RR 1.08, 95% CI 1.02–1.15). Operative time did not differ significantly between techniques (random-effects MD + 3.57 min, 95% CI − 17.25 to 24.40). Intraoperative blood loss was higher in endoscopic surgery (MD 44.0 mL, 95% CI 0.94–87.08). Rates of cerebrospinal fluid leak, epistaxis, meningitis, transient and permanent diabetes insipidus, SIADH, and postoperative visual deterioration or improvement were comparable between approaches. Both techniques demonstrate comparable perioperative safety, while endoscopic surgery seems to be associated with higher resection rates overall.</p> Graphical abstract <p></p>