Background and Aims Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD), characterized by imbalances in calcium and phosphorus homeostasis leading to compensatory overproduction of parathyroid hormone (PTH). Patients with poor response to medical treatment progress to refractory SHPT, and surgical removal of hypertrophic parathyroid glands is currently an effective method. However, surgical treatment has limitations, including high risks associated with surgery and anesthesia, as well as potential postoperative complications such as infection, permanent parathyroid dysfunction, and scar formation. With advancements in medical technology, thermal ablation has become a research focus for SHPT treatment, but standardized diagnostic and therapeutic protocols are lacking, necessitating more evidence from evidence-based medicine to facilitate the development of standardized guidelines. Therefore, this study was conducted to compare the clinical effectiveness and safety of ultrasound-guided thermal ablation with traditional parathyroidectomy (PTX) in the treatment of refractory SHPT and explore the clinical prospects of thermal ablation in the management of refractory SHPT.Methods Multiple domestic and international databases were searched to collect clinical controlled studies comparing ultrasound-guided thermal ablation with traditional open PTX in the treatment of refractory SHPT of CKD. The search period extended from the inception of each database to November 31, 2022. After applying inclusion and exclusion criteria, literature screening was conducted, and Meta-analysis was performed using RevMan 5.3 software. Evaluation indicators included serum PTH and calcium levels at 3 and 6 months postoperatively, hospitalization duration, and the incidence of hypocalcemia and hoarseness.Results A total of 12 studies involving 1 060 patients were included, with 510 in the thermal ablation group and 550 in the PTX group. Compared to the PTX group, the thermal ablation group showed no statistically significant differences in postoperative 3- and 6-month PTH levels (MD=18.18, 95% CI=-21.19-57.55, P=0.37; MD=-5.35, 95% CI=-32.59-21.90, P=0.70) and calcium levels (MD=-0.09, 95% CI=-0.28-0.10, P=0.35; MD=-0.10, 95% CI=-0.29-0.10, P=0.34). The incidence of hypocalcemia in the thermal ablation group was lower than that in the PTX group (18.5% vs. 27.3%), with a statistical difference (OR=0.57, 95% CI=0.38-0.84, P=0.005), while the incidence of hoarseness showed no significant difference between the two groups (OR=0.89, 95% CI=0.55-1.45, P=0.64). The thermal ablation group had a significantly shorter hospitalization duration than the PTX group (MD=-3.97, 95% CI=-5.68--2.27, P<0.000 1).Conclusion Ultrasound-guided percutaneous thermal ablation for SHPT may be a potential alternative to PTX, demonstrating safety, effectiveness, high repeatability, and fewer complications. However, its ultimate superiority requires confirmation through large-sample, multicenter, prospective, randomized controlled studies.