BackgroundPerioperative stress and immunosuppression may influence tumor recurrence and long-term survival in cancer patients. Dexmedetomidine, a widely used anesthetic adjunct, remains controversial regarding its impact on postoperative prognosis. Some studies suggest it may attenuate immunosuppression, whereas others point to a potential tumor-promoting effect. This meta-analysis aimed to synthesize evidence from real-world studies and evaluate the association between intraoperative dexmedetomidine use and post-surgical survival in cancer patients.MethodsWe systematically searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database, and Wanfang Database from inception to April 2026 for real-world observational studies examining the association between intraoperative dexmedetomidine use and postoperative survival in cancer patients. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Two reviewers independently screened studies, extracted data, and assessed risk of bias. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled for survival endpoints. Sensitivity analyses tested the robustness of the results, and subgroup analyses were performed according to study characteristics. Publication bias was evaluated using funnel plots, Begg’s test, and Egger’s test. All statistical analyses were conducted with Stata 15.0.ResultsEight studies comprising 4,613 patients were included. The meta-analysis revealed no statistically significant association between intraoperative dexmedetomidine use and postoperative OS (HR = 0.95, 95% CI (0.72, 1.24), P = 0.685) or RFS (HR = 0.85, 95% CI (0.61, 1.20), P = 0.363). Subgroup analyses suggested that dexmedetomidine might improve OS in colorectal cancer patients, but no such difference was observed in renal cell carcinoma or other tumor types. Across different sample sizes and geographic regions, dexmedetomidine use was not significantly associated with OS.ConclusionThis meta-analysis of real-world evidence indicates that intraoperative dexmedetomidine use is not statistically significantly associated with OS and RFS in cancer patients. Although the subgroup finding for colorectal cancer hints at a possible survival benefits, the overall evidence does not support routine dexmedetomidine administration for improving long-term oncological outcomes. Given the limited number of included studies and potential confounding factors, causal inferences should be avoided. Large-scale, prospective real-world studies are warranted to confirm these findings.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420261370773.