OBJECTIVE: This study compared the effectiveness of the endoscopic endonasal approach (EEA) with the conventional transcranial approach (TCA) for treating tuberculum sellae meningiomas (TSMs), aiming to identify the superior surgical method and the risk factors affecting outcomes. METHODS: Patients treated for TSM from 1998 to 2023 at our institution were retrospectively analyzed, evaluating patient characteristics, tumor features, outcomes, and complications. A novel grading system for preoperative evaluation of TSMs was proposed. RESULTS: Among 49 patients, 26 underwent EEA and 23 underwent TCA. The maximum diameters were comparable between the groups (mean 22 mm vs. 23 mm). Gross total resection rates were 62% for EEA and 70% for TCA, showing no significant difference. However, postsurgical visual improvement was significantly higher in the EEA group compared with the TCA group (77% vs. 44%; P = 0.020), with fewer complications in the EEA group (8% vs. 35%; P = 0.032). CONCLUSIONS: EEA is a safe and effective treatment approach for small to medium TSMs, with outcomes comparable to TCA in terms of resection but superior in visual improvement and fewer complications. Selection of surgical approach should consider patient and tumor characteristics as well as surgeon experience.