Endoscopic Third Ventriculostomy vs. Ventriculoperitoneal Shunt in Pediatric Hydrocephalus: A Systematic Review and Meta-Analysis of Efficacy, Complications, and Bias Risk

Pediatric hydrocephalus remains a common and complex condition in neurosurgical practice. Endoscopic Third Ventriculostomy (ETV) and Ventriculoperitoneal Shunting (VPS) are the two primary surgical modalities. While VPS has traditionally been the standard of care, ETV offers potential benefits in selected patients, particularly by reducing shunt dependency and infection risk. However, literature presents variable outcomes based on age, etiology, and study design. MethodsWe conducted a systematic review and meta-analysis comparing ETV and VPS in pediatric patients ([≤]18 years) with hydrocephalus. Databases searched included PubMed, Embase, Cochrane Library, and Web of Science (2010-2024). Inclusion criteria covered studies with direct ETV vs. VPS comparison, and outcomes including treatment success, complications, and long-term prognosis. We performed heterogeneity analysis (I2), sensitivity analysis, and meta-regression to explore study-level moderators such as age, sample size, and risk of bias. ResultsNine studies were included (N = 13,509; 6,365 ETV and 7,144 VPS patients). ETV demonstrated lower infection and shunt dependency rates, especially in patients over 1 year of age and in cases of obstructive hydrocephalus. VPS had slightly higher short-term success, particularly in post-hemorrhagic etiologies. Meta-regression revealed that higher bias and smaller sample sizes favored VPS outcomes ({beta} = -0.065). ETV showed better long-term cognitive and quality-of-life outcomes. Heterogeneity was low to moderate (I2 = 22.5%). ConclusionsETV is an effective alternative to VPS in appropriately selected pediatric patients, particularly those older than 6 months with obstructive hydrocephalus. The benefits include lower infection rates and long-term dependency. However, the success of ETV is highly dependent on patient selection and surgical expertise. This review underscores the need for standardized reporting, stratification by age and etiology, and high-quality randomized controlled trials to guide clinical decision-making.