BACKGROUND: The optimal treatment strategy for recurrent hepatocellular carcinoma (rHCC) remains unclear. This study is based on cases of rHCC after liver resection, aiming to evaluate the influence of preoperative risk factors on the long-term prognosis of patients with rHCC by comparing patients who underwent salvage liver transplantation (SLT) with those who underwent repeat hepatectomy (RH). METHODS: We retrospectively analyzed 401 consecutive patients with rHCC who underwent SLT or RH between March 2015 and December 2022. Next, we performed propensity score matching, subgroup analyses, and both univariate and multivariate analyses. In addition, Kaplan-Meier analysis was used to estimate the overall survival (OS) and recurrence-free survival (RFS) after recurrence. RESULTS: The 1-, 3-, and 5-year OS and RFS rates in the SLT group were significantly higher than those in the RH group (p=0.0131 and p=0.0010, respectively), and similar results were observed after propensity score matching. In the presence of zero or one risk factors, the OS and RFS in the SLT group were significantly better than those in the RH group (p=0.0386 and p=0.0117, respectively). However, in the presence of two to four risk factors, no significant differences in OS or RFS were detected between the two groups (p=0.1119 and p=0.1035, respectively). CONCLUSION: Our analysis identified a number of risk factors that were strongly correlated with a long term prognosis for patients with rHCC who underwent SLT and RH: multiple tumors, a maximum tumor diameter ≥5 cm, microvascular invasion, and a recurrence time ≤2 years. Our findings provide important reference guidelines for organ allocation and clinical decision-making.