Introduction: The ideal surgical trajectory to craniopharyngiomas points through the nasal cavity. The magnification and illumination of the endoscope and nasoseptal flap utilization against CSF leakage made it possible that endoscopic endonasal surgery became the most favourable approach.

Aims: We illustrate our early results with endonasal endoscopic craniopharyngioma surgery to facilitate a constructive discussion about techniques, potential complications and therapeutic strategies.

Methods: We have retrospectively examined our craniopharyngioma cases treated with endonasal endoscopic surgery in the last two years. Tumor extent, surgical videos, resection rates, ophthalmological and endocrinological outcomes, and complications were analyzed.

Results: Nine patients were operated using an uninostril purely endoscopic transethmoidal-paraseptal approach. Five patients had at least one transcranial operation in their history. Postoperative MRI verified macrototal resection in all 9 cases. Until April 2024 two patients had a tumor recurrence. Four of the patients were endocrinologically already fully substituted before the operation. One patient under partial substitution and one without stayed unchanged. Three partially substituted patients needed additional hormonal therapy. Memory impairment was noted in one patient. Visual functions improved in 6 cases, stayed unchanged in 2 cases, and showed worsening in one case due to an occipital hemorrhage. CSF leakage was experienced in two cases and were cured with lumbar drainage and in one case with surgery. Sinonasal outcome test was performed in 8 of the patients preoperatively and 3 months after the surgery. Good nasal function with mild deterioration was recorded in 4 cases, improvement in 3 cases, and unchanged status in 1 case.

Conclusion: Even large tumors can be resected through an uninostril approach with only dorsal resection of the nasal septum, preservation of the turbinates and nasal functions. Neurological and endocrinological impairments caused by surgery must be reduced to achieve a better quality of life. Irradiaton is indicated in selected cases but recurrent tumors may still need repeated surgery.

Funding: no funding involved.