Vestibular schwannomas (VS) are benign tumors arising from the Schwann cells of the vestibular nerve. They represent one of the most common causes of unilateral sensorineural hearing loss and are frequently associated with symptoms such as tinnitus, vertigo, and, in advanced cases, cerebellar and brainstem dysfunction [[1], [2], [3]].

The selection of a surgical approach for vestibular schwannoma management is a pivotal aspect of disease treatment, as it significantly influences outcomes such as hearing preservation, postoperative complications, and overall quality of life. Among the microsurgical techniques available, the translabyrinthine and middle fossa approaches are the most commonly employed, each offering distinct advantages and limitations [3]. In addition, the retrosigmoid approach represents another well-established option for vestibular schwannoma resection [4]. Importantly, for small to medium tumors, meta-analyses suggest that the retrosigmoid approach may offer superior hearing preservation compared with the middle fossa technique, while maintaining equivalent facial nerve outcomes [5,6]. For larger lesions, the decision between retrosigmoid and translabyrinthine approaches hinges on the trade-off between hearing preservation and surgical exposure, given that the latter inherently sacrifices hearing [4,6,7].

The translabyrinthine (TL) approach, frequently utilized for large tumors, provides excellent access for complete tumor resection and is associated with high rates of facial nerve preservation. However, this technique invariably results in permanent hearing loss on the affected side [3,8]. Conversely, the middle cranial fossa (MCF) approach prioritizes the preservation of functional hearing but presents notable anatomical challenges and greater technical complexity [3,9]. Despite substantial research in this area, there remains no clear consensus on which approach delivers superior outcomes in terms of functional results, complication rates, and overall efficacy. Given these differing characteristics, a crucial question arises: which surgical approach, translabyrinthine or middle fossa, yields better outcomes regarding hearing preservation, tumor resection rates, and postoperative complications?

To address this gap, the present study aims to conduct a systematic review and comparative meta-analysis of the translabyrinthine and middle fossa approaches in vestibular schwannoma surgery. Specifically, we seek to evaluate these approaches concerning key clinical outcomes, including reoperation rates and associated complications.