BACKGROUND: Endoscopic trans-sphenoidal surgery has been increasingly replacing microscopic surgery as the state of the art trans-sphenoidal approach.OBJECTIVE OF REVIEW: To assess the efficacy and safety of pure endoscopic approach in comparison with microscopic approach in pituitary surgery.TYPE OF REVIEW: Literature review and meta-analysis.SEARCH STRATEGY: Systematic literature searches of MEDLINE (1952-10th February 2010), EMBASE (1974-10th February 2010) and the Cochrane Central Register of Controlled Trials to the 10th February 2010.EVALUATION METHOD: Review of all English-language studies comparing endoscopic and microscopic techniques.RESULTS: Eleven relevant studies were identified with a total of 806 patients, 369 of whom had endoscopic surgery and 437 microscopic surgery. The initial remission rate of hypersecretion of functioning adenomas was not significantly different between the endoscopic and the microscopic group [(OR: 1.34(95% CI: 0.73-2.47); P=0.35; 66% remission rate in endoscopic group versus 60% in microscopic)].The proportion of patients with complete tumour removal was not significantly different in the endoscopic group than in the microscopic group [(OR: 0.83, (95% CI: 0.52-1.33); P=0.44]. The rate of CSF leak attributable to the surgical method did not differ significantly between endoscopic and microscopic group. Post-operative diabetes insipidus was less frequent in those having endoscopic surgery [15%versus 28%P=0.003]. Regarding the other intra cranial and nasal complications attributable to surgical technique, the occurrence rate in endoscopic group was significant lower compared with microscopic group (13%versus 1.2% respectively, P<0.05). Patients in the endoscopic group had significant shorter postoperative hospital stay with a range from 3.7 to 4.4 days, than those of microscopic group with a range from 5.4 to 5.7 days [(WMD: -1.53, (95% CI: -2.30 to -0.77); P<0.00001)].CONCLUSIONS: Notwithstanding its limitations, the present systematic review, based on the currently available evidence, suggests that endoscopic trans-sphenoidal pituitary surgery is associated with similar rates of complete tumour excision and remission rates. Endoscopic surgery was associated with fewer complications related to surgical technique and a shorter hospital stay.