Outcomes of endoscopic third ventriculostomy with or without choroid plexus cauterization in paediatric hydrocephalus management in Africa: a systematic review and meta-analysis

Endoscopic third ventriculostomy (ETV), performed alone or combined with choroid plexus cauterization (CPC), is increasingly used as an alternative to cerebrospinal fluid shunting for pediatric hydrocephalus in Africa. However, treatment outcomes vary across clinical settings, and the comparative effectiveness of ETV alone and ETV/CPC remains uncertain. This systematic review and meta-analysis synthesized the available evidence on the outcomes of ETV with or without CPC in African children with hydrocephalus. This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, CINAHL, African Journals Online, and Google Scholar were searched from database inception through 31 July 2026. Eligible studies included children younger than 18 years who underwent ETV alone, ETV combined with CPC, or procedures reported within mixed ETV and ETV/CPC cohorts in African countries. The primary outcome was treatment success, defined as freedom from repeat cerebrospinal fluid diversion during follow-up. Postoperative complications and mortality were assessed separately. Study-level proportions were pooled using a DerSimonian–Laird random-effects model following logit transformation. Heterogeneity was assessed using Cochran’s Q, I², and τ², and a 95% prediction interval was calculated. Prespecified subgroup analyses were performed according to procedure category and risk of bias. Leave-one-out sensitivity analysis, funnel-plot inspection, and Egger’s regression test were also performed. Risk of bias was evaluated using ROBINS-I for non-randomized studies and RoB 2 for randomized trials. A total of 27 studies involving 2,808 children were included in the systematic review, of which 24 studies involving 2,724 children contributed to the quantitative synthesis. Sex was reported for the eligible ETV/ETV + CPC cohort in 19 of the 27 included studies; among the 1,279 participants with sex-specific data, 762 were male and 517 were female (59.6% male). Across the meta-analysis, 1,609 children achieved treatment success. The pooled treatment success rate was 65.2% (95% confidence interval [CI] 59.3%–70.6%). Between-study heterogeneity was substantial (I² = 85.9%; τ² = 0.268), and the 95% prediction interval ranged from 39.7% to 84.2%. Subgroup analyses showed pooled treatment success rates of 67.8% (95% CI 56.9%–77.0%) for ETV-alone cohorts, 65.6% (95% CI 47.8%–79.9%) for ETV/CPC cohorts, and 64.5% (95% CI 54.6%–73.4%) for mixed-procedure cohorts. The confidence intervals overlapped substantially, providing no clear evidence of a difference in treatment success between ETV alone and ETV/CPC. In the leave-one-out sensitivity analysis, pooled estimates ranged from 63.3% to 66.5%, indicating that no individual study disproportionately influenced the overall result. Funnel-plot asymmetry and Egger’s regression test suggested possible small-study effects (intercept 2.26, standard error 0.81; p = 0.011), although this finding should be interpreted cautiously because of the substantial clinical and methodological heterogeneity. ETV with or without CPC was associated with an overall treatment success rate of approximately 65% among children with hydrocephalus in African settings. The available evidence does not demonstrate a definitive advantage of ETV/CPC over ETV alone because the procedure-specific estimates were derived largely from observational studies and indirect comparisons and had substantially overlapping confidence intervals. The considerable heterogeneity and wide prediction interval indicate that outcomes vary markedly across clinical environments. Standardized definitions of treatment success, longer follow-up, multicenter prospective studies, and adequately powered head-to-head randomized trials are needed to establish comparative effectiveness and improve the generalizability of recommendations across Africa.