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Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Pubmed and Embase databases were searched for studies (2000\u20132020) that (a)\u00a0reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and\/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used\u00a0for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with\u00a0higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases\u00a0was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3\u20134.5%) for transsphenoidal, 9% (CI 7.2\u201311.3%) for expanded endonasal, and 5.3% (CI 3.4\u20137%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Modern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. 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