Purpose <p>Focal cryoablation is an effective treatment for localized and recurrent prostate cancer, offering reduced risks of side effects. However, treatment success depends on physician experience, as intraprocedural adjustments are required due to needle deflection. To determine whether an image-guided adaptive treatment strategy could reduce the required years of experience, we developed Image-guided Adaptive Cryotherapy (ImAC). We hypothesize that ImAC can be successfully implemented in MRI-guided cryotherapy to optimize needle placement. To test this hypothesis, we conducted a retrospective study comparing the performance of an experienced physician to that of ImAC.</p> Methods <p>ImAC was designed to calculate the best subsequent needle location while accounting for needle deflection and iceball formation. After development, its performance was evaluated by simulating 21 needle insertions.</p> Results <p>We found that ImAC achieved a higher median minimum ablation margin than the physician (5.0 vs 3.4 mm) while maintaining similar needle placement adjustments (± 7.5 mm).</p> Conclusion <p>These results suggest that ImAC has the potential to optimize needle placement and may reduce the years of experience required for effective cryoablation.</p>