Introduction: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. While transarterial chemoembolization (TACE) and microwave ablation (MWA) are established treatments for unresectable HCC, the comparative efficacy of TACE combined with MWA versus MWA alone remains unclear. This is the first meta-analysis to evaluate survival, recurrence, and safety outcomes between these strategies. Methods: Following PRISMA guidelines, we systematically searched PubMed, Embase, Cochrane Library, and Web of Science (inception–April 2024) for randomized controlled trials (RCTs) and observational studies comparing TACE+MWA with MWA alone. The risk of bias was assessed using the Cochrane RoB 2.0 tool and the Newcastle-Ottawa Scale. Meta-analyses were conducted using random-effects models in RevMan Web. Results: Eight studies, comprising 1,336 patients (502 TACE+MWA, 834 MWA alone), met the inclusion criteria. TACE+MWA significantly reduced disease progression/recurrence (OR=0.64, 95% CI:0.42–0.97; p=0.04) but showed no survival benefit at 1-year (OR=1.71, 95% CI:0.79–3.72), 3-year (OR=1.47, 95% CI:0.99–2.18), or 5-year (OR=0.58, 95% CI:0.28–1.21) compared to MWA alone. Subgroup analyses revealed improved 3-year survival (OR=1.91, 95% CI:1.09–3.36; p=0.02) and reduced progression/recurrence (OR=0.44, 95% CI:0.25–0.78; p=0.005) for tumors >3 cm and <5 cm. No differences emerged in recurrence-free survival, mean survival time, or adverse events. Conclusion: TACE + MWA reduces disease progression and improves 3-year survival for tumors between 3–5 cm, whereas MWA alone may be non-inferior to the TACE + MWA combination therapy for tumors <3 cm. Future studies should standardize treatment intervals and conduct tumor-specific subgroup analyses to optimize clinical decision-making.