Objective To compare of the efficacy and safety of neuroendoscopic endonasal transsphenoidal surgeries and intracranial endoscopic pterional approach in resection of tuberculum sellae meningioma. Methods From January 2014 to June 2021, 60 patients with tuberculum sellae meningioma diagnosed and treated in our hospital were enrolled and randomly divided into study group and control group. The tuberculum sellae meningioma was removed by neuroendoscopic endonasal transsphenoidal surgeries in the study group, while the intracranial endoscopic pterional approach was used in the control group. The chi-square test was used to compare the differences of tumor complete resection rate, visual acuity improvement rate, total effective rate at 3 months after operation, and adverse reactions between the two groups. Results The clinical characteristics of the two groups were comparable ( P > 0.05). After surgical treatment, the complete resection rate in the study group was higher than that in the control group (93.3% vs 70.0%), and the difference was statistically significant ( P =0.020). After treatment, the visual acuity improvement rate of the study group was 83.3% (25/30), which was significantly higher than that of the control group (60.0%, 18/30), and the difference was statistically significant ( χ 2 = 4.022, P =0.045). After surgical treatment, the total effective rate at 3 months after operation was higher in the study group than in the control group (96.7% vs 83.3%), with statistical significance ( P =0.041). There was no significant difference in postoperative adverse reactions between the study group and control group (33.3% vs 30.0%, P =0.781). Conclusion The neuroendoscopic endonasal transsphenoidal surgeries has significant efficacy and can significantly improve the visual acuity of patients without increasing adverse reactions, which is worthy of clinical promotion.