<p>Basal ganglia hemorrhage (BGH) is a prevalent site for intracerebral hemorrhage. Although neuroendoscopy (NE) surgery has emerged as a less invasive alternative to craniotomy (CT), the optimal surgical method remains debatable. This systematic review and meta-analysis aimed to compare the efficacy and safety of NE versus CT in the management of BGH. A systematic search of PubMed, Embase, Cochrane Library, and Web of Science databases was conducted to identify eligible randomized controlled trials (RCTs) comparing NE surgery with CT in BGH patients. Outcomes included mortality, hematoma evacuation rate, good functional outcome (GFO), operative time, infection, pulmonary infection, and postoperative complication. Risk of bias was assessed with Cochrane’s ROB-2 tool. Four RCTs were included, comprising 423 patients. NE surgery showed no significant benefit in mortality (<i>p</i> = 0.12) and GFO (<i>p</i> = 0.18). However, NE was associated with a higher hematoma evacuation rate (<i>p</i> = 0.007), shorter operative time (<i>p</i> &lt; 0.00001), and lower rates of infection (<i>p</i> &lt; 0.0001), pulmonary infection (<i>p</i> &lt; 0.0001), and postoperative complications (<i>p</i> &lt; 0.00001). Future research should be designed to assess whether hematoma evacuation using either technique improves outcomes in comparison to optimal medical management in this population.</p>