<p>Surgery for posterior fossa tumors carries a high risk of cerebrospinal fluid (CSF)-related complications, including leaks and pseudomeningocele, which increase morbidity, prolonged hospital stay, and contribute to healthcare costs. While advances in dural closure techniques and sealants have aimed to reduce these complications, the choice between craniotomy (bone flap replacement) and craniectomy (bone removal without replacement) remains variable and lacks consensus. This systematic review and meta-analysis aimed to compare postoperative outcomes between these two surgical techniques in the specific context of posterior fossa tumor resection.&#xa0;A systematic search of PubMed, Embase, and Web of Science through March 2025 identified eligible studies. The protocol was registered in PROSPERO (CRD420251038861). Studies comparing craniotomy and craniectomy in posterior fossa tumor surgery and reporting outcomes of interest (CSF leak, pseudomeningocele, hydrocephalus, wound or CNS infection, length of stay) were included. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the GRADE framework. Meta-analyses were performed using random-effects models.&#xa0;Four studies comprising 385 patients were included. Craniotomy significantly reduced the risk of CSF leak (OR: 0.19; 95% CI: 0.07–0.48) and pseudomeningocele (OR: 0.27; 95% CI: 0.13–0.57), and decreased hospital stay by an average of 3.4 days (MD: − 3.35; 95% CI: − 5.71 to − 0.99) compared to craniectomy. These findings correspond to an absolute risk reduction of approximately 11% for CSF leak and pseudomeningocele, with a number needed to treat of 9 to prevent one additional complication. No significant differences were observed for postoperative hydrocephalus, wound infection, or CNS infection. The certainty of evidence was rated as moderate for CSF-related outcomes and length of stay, and low for infection-related outcomes and hydrocephalus. Craniotomy may be associated with reduced CSF-related complications and shorter hospital stay compared with craniectomy in posterior fossa tumor surgery. These findings support the potential role of bone flap replacement in reducing morbidity and healthcare burden; however, the evidence remains limited by the small number and observational design of available studies, warranting cautious interpretation. Well-designed prospective trials are warranted to validate these associations and guide standardized reconstruction strategies in this high-risk population.</p>