Objective: This study aimed to compare the efficacy, safety, and diagnostic yield of three biopsy approaches for pineal tumors: endoscopy-, stereotaxic-, and neuronavigation-guided techniques. Methods: A systematic review and meta-analysis were conducted, encompassing relevant studies published between 1973 and 2023. Data were collected on biopsy success rates, complications, diagnostic accuracy, and procedural variables. Results: A total of 93 studies met the inclusion criteria, comprising 1798 patients. We did not find any article considering only neuronavigation. This technique was always associated with the endoscopic or the stereotactic way, so we did not present isolated results. The overall biopsy success rates were comparable for both techniques, ranging from 25% to 100% (We note that three studies reported very low success rates (25%–50%) compared with the remaining 45 studies, which reported success rates ranging from 81.1% to 100%. These studies are discussed, along with our interpretation of these exceptions: (1) Kraichoke et al. (Am J Surg Pathol 12(9):655–660, 1988), success rate = 25% (n = 4); this result is probably due to the early stage of adoption of the technique. (2) Cunliffe et al. (J Neurooncol 93(2):269–274, 2009), success rate = 50% (n = 1); a second biopsy was performed for the same patient because the first one only provides hemorrhagic tissue fragments. (3) Kim et al. (Childs Nerv Syst 39(9):2367–2375, 2023), success rate = 50% (n = 2); one endoscopic procedure had to be stopped because of hemorrhage resulting in poor visualization.). However, endoscopic biopsies demonstrated a slightly lower diagnostic yield (87%) compared to stereotaxic-guided techniques (94.6%). Complication rates were also similar, with minor complications occurring in 4.3%–14.9% of cases and major complications in 0.5%–1.6%. Conclusion: Endoscopic-, stereotaxic-, and neuronavigation-guided biopsy techniques exhibit similar efficacy and safety profiles for sampling pineal tumors. Endoscopy may offer a significant advantage due to the possibility to perform an endoscopic third ventriculostomy (ETV) in the same surgical time, but the choice of technique should consider individual patient factors, tumor characteristics, and surgeon expertise. Further prospective studies are warranted to validate these findings and optimize biopsy strategies for pineal tumors.