Purely suprasellar Rathke's cleft cysts (RCC) treated with a microscopic endonasal approach have increased operative morbidity and poorer outcomes compared to purely sellar RCC. We sought to determine if the extended endoscopic endonasal approach improved outcomes for suprasellar RCC. We retrospectively reviewed RCC patients at our institution over a 10 year period comparing outcomes of purely sellar RCC treated microsurgically (n=68), purely suprasellar RCC treated microsurgically (n=22), and purely suprasellar RCC treated endoscopically (n=9). Suprasellar RCC treated endoscopically were similar in size to those treated microscopically (0.9 versus 1.1cm; p=0.4). Complete cyst drainage occurred in 78% of suprasellar RCC approached endoscopically versus 25% approached microsurgically (p=0.02), approaching the 84% complete drainage rate seen with sellar microsurgically approached RCC. Visual normalization occurred in 67% of suprasellar RCC patients treated endoscopically versus 29% treated microsurgically (p=0.5). Headache improved in 71% of suprasellar RCC treated endoscopically, more than the 33% of suprasellar RCC treated microsurgically and the 53% of sellar RCC treated microsurgically (p=0.4). Diabetes insipidus (all temporary) occurred in 22% of patients with suprasellar RCC treated endoscopically, slightly greater than the 14% in suprasellar microsurgical patients and 9% in sellar RCC treated microsurgically (p>0.05). Cerebrospinal fluid (CSF) leak did not occur in any of the suprasellar RCC treated endoscopically, while 14% treated microsurgically experienced a CSF leak (p>0.05). Suprasellar RCC are neurosurgically challenging due to their proximity to the optic chiasm and infundibulum. Compared to microsurgery, endoscopy improves rate of complete removal and visual outcomes.