RATIONALE AND OBJECTIVES: Ultrasound-guided thermal ablation (TA) offers a minimally invasive alternative to surgery for T1N0M0 papillary thyroid carcinoma (PTC), but its efficacy and safety remain controversial. This meta-analysis aimed to evaluate and compare the outcomes of TA and surgery in treating T1N0M0 PTC, encompassing both T1a and T1b stages. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis including studies comparing TA and surgery for T1N0M0 PTC up to October 23, 2024. Standardized mean differences and odds ratios (OR) with 95% confidence intervals (CI) were calculated for primary and secondary outcomes. RESULTS: Sixteen studies with a total of 5045 patients were analyzed. No significant differences were observed in recurrence (OR=1.464
95% CI=0.881, 2.433
P=.141), lymph node metastasis (OR=0.817
95% CI=0.492, 1.356
P=.434), transient hoarseness (OR=0.700
95% CI=0.339, 1.445
P=.334), hematoma (OR=0.528
95% CI=0.187, 1.492
P=.228), and infection (OR=0.368
95% CI=0.060, 2.268
P=.281). Notably, TA significantly reduced permanent hoarseness, hypoparathyroidism, dysphagia, procedure time, hospitalization, cost, estimated blood loss, and surgical incision (all P<
.05). The subgroup analyses demonstrated similar primary outcomes within each subgroup, including tumor stage (T1a/T1b), type of TA (microwave/radiofrequency), and follow-up time (short-term/long-term). CONCLUSION: Ultrasound-guided TA is a safe and effective alternative to surgery for both T1a and T1b stages of T1N0M0 PTC, offering comparable prognostic outcomes with fewer complications, lower costs, and faster recovery.