In an investigation of the benefits and risks of direct surgical approaches to pediatric pineal tumors, the need for such approaches, the feasibility of surgical removal and operative complications were evaluated in 25 histologically proven cases. Five tumors were germinomas (GEs) or GE-predominant mixed germ cell tumors (GCTs), in which stereotactic biopsy can be adequate. Twenty of the 25 pineal tumors (80%) were teratomas (TEs), TE-predominant mixed GCTs or other tumors that need direct surgical approaches. Among the 21 tumors resected by the occipital transtentorial (OTT) approach, 13 were removed radically (>95%) and 6 others, subtotally (>75%). Complications of using the OTT approach included homonymous hemianopsia (7), Parinaud's syndrome (6), other eyeball movement limitation (7), seizure (5), and new hydrocephalus (3). The majority of these were transient, resolving within a few days or months, or easily controlled. The results showed that 80% of pediatric pineal tumors needed direct surgical approaches and that the majority were successfully removed by OTT surgery with an acceptable level of risk.