Background: The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, published in 2009, aimed to help systematic reviewers prepare a transparent report of their review. Advances in systematic review methodology and terminology over the last decade necessitated an update to the guideline. A detailed description of the updating process may provide a useful roadmap for others embarking on a similar initiative.Objectives: To (i) describe the processes used to update the PRISMA 2009 statement for reporting systematic reviews, (ii) present results of a survey conducted to inform the update, (iii) summarise decisions made at the PRISMA update meeting, and (iv) describe and justify changes made to the guideline.Methods: We reviewed 60 documents with reporting guidance for systematic reviews to generate suggested modifications to the PRISMA 2009 statement. We invited 220 systematic review methodologists and journal editors to complete a survey about the suggested modifications. The results of these projects were discussed at a 21-member in-person meeting. Following the meeting, we drafted the PRISMA 2020 statement and refined it based on feedback from co-authors and a convenience sample of 15 systematic reviewers. Results: The review of 60 documents with reporting guidance for systematic reviews resulted in a bank of 221 unique reporting items and revealed that all topics addressed by the PRISMA 2009 statement could be modified or supplemented with additional guidance. Of the 110 respondents to the survey, more than 66% recommended keeping six of the 27 PRISMA 2009 checklist items as they were and modifying 15 of the checklist items using wording suggested by us; there was no consensus on what to do with the remaining six items. Attendees at the in-person meeting supported the revised wording for several items but suggested rewording for most items to enhance clarity, and further refinements were made over six drafts of the guideline. Conclusions: The PRISMA 2020 statement consists of updated reporting guidance for systematic reviews and reflects advances over the last decade in methods to identify, select, appraise and synthesise studies. We hope that providing this detailed description of the development process will enhance the acceptance and uptake of the guideline and assist those developing and updating future reporting guidelines.