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Background: Intraoperative magnetic resonance imaging (iMRI) allows for greater tumor visualization and extent of resection. It is increasingly used in transsphenoidal surgeries but its role is not yet established., Objective: We aimed to clarify the usefulness of iMRI in transsphenoidal surgery using direct statistical comparisons, with additional subgroup and regression analyses to investigate which patients benefit the most from iMRI use., Methods: Systematic searches of PubMed, Embase, and Cochrane Central were undertaken from database inception to May 2020 for published studies reporting the outcomes of iMRI use in transsphenoidal resection of pituitary adenoma., Results: Thirty-three studies reporting 2106 transsphenoidal surgeries in 2099 patients were included. Of these surgeries, 1487 (70.6%) were for nonfunctioning pituitary adenomas, whereas 619 (29.4%) were for functioning adenomas. Pooled gross total resection (GTR) was 47.6% without iMRI and 66.8% with iMRI (risk ratio [RR], 1.32; P < 0.001). Subgroup and meta-regression analyses demonstrated comparable increases in GTR between microscopic (RR, 1.35; P < 0.001) and endoscopic (RR, 1.31; P < 0.001) approaches as well as functioning and nonfunctioning adenomas (P = 0.584). The pooled rate of hypersecretion normalization was 73.0% within 3 months and 51.7% beyond 3 months postoperatively. The pooled rate of short-term and long-term improvement in visual symptoms was 96.5% and 84.9%, respectively. The incidence of postoperative surgical complications was low. The pooled reoperation rate was 3.8% across 1106 patients., Conclusions: The use of iMRI as an adjunct significantly increases GTR for both microscopic and endoscopic resection of pituitary adenomas, with comparable benefits for both functioning and nonfunctioning adenomas. Satisfactory endocrinologic and visual outcomes were achieved., (Copyright © 2022 Elsevier Inc. All rights reserved.)