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OBJECTIVE: The purpose of this review is to assess and critically appraise the current scientific evidence comparing thermal ablation and surgical approaches in the management of symptomatic benign thyroid nodules (SBTN) in terms of efficacy and safety. METHODS: This systematic review was conducted in accordance with established PRISMA guidelines. A comprehensive literature search was carried out using PubMed, EMBASE, and Cochrane CENTRAL databases up to July 2024. The primary outcomes assessed were procedural success and safety. RESULTS: Three studies showed comparable efficacy rate, while 4 others resulted in higher efficacy rate for surgery [fixed-effects model: odds ratio (OR) = 0.06, 95% confidence interval (CI) (0.01-0.27)]. The results demonstrated that the complication rate [OR 0.28, 95% CI (0.13-0.58)] and both procedural time [random-effects model: mean difference (MD) = -53.67, 95% CI (-64.99 to -42.34)] and hospital stay duration [random-effects model: MD = -3.86, 95% CI (-4.90 to -2.82)] favoured thermal ablation (TA) over surgery. Global costs [random-effects model: MD = -777.91, 95% CI (-2583.07 to 1027.25)] were lower for TA compared to surgery, but not reaching a statistically significant threshold. CONCLUSION: Image-guided thermal ablation techniques constitute safe and effective treatment modalities for SBTN, offering advantages over surgery in terms of lower complication rates, shorter procedure times, and reduced hospital stays, while showing no significant difference in overall costs. Efficacy in terms of volume reduction is arguably higher for surgery, but further studies are needed, given the diverse and controversial results encountered. ADVANCES IN KNOWLEDGE: Image-guided thermal ablation techniques appear to be a safe and effective therapeutic option for the management of SBTN.