OBJECTIVE: To compare the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) for detecting urinary tract endometriosis (UTE), including ureteral and bladder involvement. METHODS: A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. PubMed, Embase, and Scopus were searched from inception to December 2025 for diagnostic accuracy studies evaluating TVUS and/or MRI for UTE. Surgical findings, with or without histopathological confirmation, were used as the reference standard. Studies reporting sufficient data to construct 2 × 2 contingency tables were included. Pooled sensitivity and specificity with 95% confidence intervals (CI) were calculated using a bivariate random-effects model, with separate analyses for ureteral and bladder endometriosis. RESULTS: Thirty-six studies met the inclusion criteria. For ureteral endometriosis, TVUS demonstrated a pooled sensitivity of 0.89 (95% CI 0.65-0.97) and specificity of 1.00 (95% CI 0.97-1.00), while MRI showed a pooled sensitivity of 0.96 (95% CI 0.50-1.00) and specificity of 1.00 (95% CI 0.96-1.00). For bladder endometriosis, TVUS yielded a pooled sensitivity of 0.70 (95% CI 0.55-0.81) and specificity of 1.00 (95% CI 0.99-1.00), whereas MRI demonstrated a pooled sensitivity of 0.77 (95% CI 0.58-0.89) and specificity of 0.99 (95% CI 0.98-1.00). Substantial heterogeneity was observed, particularly for sensitivity estimates. CONCLUSION: TVUS and MRI show excellent specificity for diagnosing urinary tract endometriosis. MRI provides slightly higher sensitivity for ureteral disease, while both modalities demonstrate moderate sensitivity for bladder involvement. A complementary, site-specific imaging approach is, therefore, supported, with cautious interpretation of negative findings.