Simultaneous bilateral total hip arthroplasty (SimBTHA) offers benefits such as reduced hospital stay and costs for patients with bilateral hip disease. However, the optimal surgical approach remains uncertain. This study aimed to compare the perioperative outcomes of SimBTHA performed via the direct anterior approach (DAA) versus the posterior approach (PA). A systematic review and meta-analysis were conducted, including studies reporting outcomes of SimBTHA using DAA and PA. The primary outcome was the incidence of allogeneic blood transfusions, while secondary outcomes included blood loss and surgical complications, such as dislocations, periprosthetic fractures, and infections. Six studies were included, analyzing 944 patients, with 372 undergoing SimBTHA via DAA and 572 via PA. No significant difference was observed in the number of allogeneic blood transfusions between the two approaches (RR = 1.04; 95% CI: 0.76 to 1.43; p=0.63). DAA was associated with significantly lower blood loss compared to PA (MD = -31.51 mL; 95% CI: -43.07 to -19.94 mL; p=0.07). However, there was no significant difference in the rates of surgical complications between the two groups (RR = 0.63; 95% CI: 0.32 to 1.26; p=0.12). While DAA showed a benefit in reducing blood loss, it did not demonstrate superiority over PA regarding transfusion rates or surgical complications. These findings highlight the need for further randomized controlled trials with standardized methodologies and longer follow-up periods to better assess the optimal approach for SimBTHA.