Hepatocellular carcinoma (HCC) is the most common primary liver cancer with an extremely high recurrence rate. Due to the absence of definitive treatment guidelines for recurrent HCC, this study assessed the effectiveness of repeat resection (RR) versus percutaneous radiofrequency ablation (RFA) in patients initially diagnosed with Barcelona clinic liver cancer staging system (BCLC) stage 0-A primary HCC who developed no more than three recurrent tumors, each ≤3 cm in size, after curative resection.This study retrospectively analyzed patients diagnosed with recurrent HCC between January 1, 2010, and May 30, 2022, across five centers, who underwent either RR or RFA. All patients met the eligibility criteria for both treatments.This study included 464 patients (224 in the RR group and 240 in the RFA group). Both groups were predominantly male (87.1% vs. 82.9%) and aged ≤60 years (72.8% vs. 69.9%). The groups showed differences in histological differentiation of initial tumors and size of recurrent tumors, but these baseline characteristics were balanced after propensity score matching. The median overall survival (OS) after retreatment was 100.3 months in the RR group and 67.4 months in the RFA group (HR: 0.612, 95% CI: [0.414-0.904], p = 0.013). The median recurrence-free survival (RFS) after retreatment was 34.6 months in the RR group and 16.2 months in the RFA group (HR: 0.574, 95% CI: [0.447-0.737], p < 0.001). Both RFS and OS were significantly better in the RR group than in the RFA group.In patients with primary HCC classified as BCLC stage 0-A who have undergone curative resection, RR is superior to RFA in terms of both RFS and OS when the recurrent tumors are ≤3 in number and ≤3 cm in size.© 2025 S. Karger AG, Basel.