Introduction: Neural injuries during gynecological, urological, colorectal, and spinal surgeries affecting pelvic structures can result in life-altering dysfunction affecting bladder, bowel, and sexual health. Intraoperative neurophysiological monitoring (IONM) is a promising approach to mitigate surgical risks. In this systematic review with meta-analysis following PRISMA guidelines, we hypothesized that IONM could reduce postoperative deficits, maintain pelvic functions, and enhance improvement rates for high-risk procedures. Methods: A systematic review of databases, including PubMed, ScienceDirect, and Scopus (1965-2024), was conducted per PRISMA guidelines. Studies were included if they reported post-operative outcomes in human subjects undergoing relevant surgeries, with at least ten patients per study. Case reports, conference abstracts, animal studies, and non-English publications were excluded. The IONM search included terms like "external urinary sphincter monitoring," "bladder EMG," "bladder motor evoked potential," "BCR," and "pudendal nerve SSEP." The non-IONM search encompassed keywords such as "hysterectomy," "colorectal surgery," "cauda equina surgeries," and "tethered cord release." Results: Statistical analysis focused on spinal-related procedures due to insufficient comparative data in urological, colorectal, and gynecological subsections. Analysis included 771 patients, 482 receiving IONM, and 289 without IONM. Chi-square testing showed statistically significant variations in outcome distributions (p < 0.0001 for improvement, baseline maintenance, and deterioration). The odds ratio of 0.32 shows that IONM patients were 68% less likely to improve postoperatively, an unexpected finding requiring interpretation. Odds ratio for baseline function was 4.42, indicating that IONM patients were over four times more likely to maintain baseline function. IONM correlated with a 67% reduction in neurological deterioration risk. Discussion: Our findings confirm that multimodality IONM is reliable for preserving neural function during high-risk surgeries. Lower improvement rates likely reflect its application in complex cases. Significant literature gaps persist regarding standardized pelvic-specific IONM protocols; future research is necessary.