<p>Hearing preservation remains a key goal in the management of vestibular schwannoma. Here, we aimed to evaluate long-term hearing and facial nerve outcomes following hearing preservation surgery for VS. A systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed and Embase were searched for studies reporting long-term hearing outcomes after VS resection via the retrosigmoid or middle fossa approach. Studies with at least a 5-year follow-up were included. The primary outcome was long-term serviceable hearing, defined as American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Class A or B. The secondary outcome was long-term preservation of facial nerve function, defined as House-Brackmann Grade I. Of the 1806 studies screened, a total of 8 studies reporting 310 patients with long-term hearing outcomes and 228 patients with facial nerve outcomes were included in the meta-analysis. The pooled proportion of patients with long-term serviceable hearing was 60% (95% CI: 52%–68%), with no significant difference between the retrosigmoid (57%) and middle fossa (60%) approaches (<i>p</i> = 0.63). Facial nerve function was well preserved, with 94% (95% CI: 72%–99%) of patients achieving House-Brackmann Grade I facial nerve function at long-term follow-up. No significant difference was observed between the two surgical approaches in terms of facial nerve function preservation (<i>p</i> = 1.000). In conclusion, long-term preservation of hearing function is feasible in the surgical management of VS and is associated with excellent facial nerve outcomes, with comparable outcomes observed between the retrosigmoid and middle fossa surgical approaches.</p>