Objective To investigate the prognostic benefits of sorafenib following radiofrequency ablation (RFA) in patients with recurrent hepatocellular carcinoma (RHCC) and microvascular invasion (MVI) after initial resection.Methods A retrospective analysis was conducted on 173 RHCC patients with MVI who underwent initial hepatectomy between January 2011 and December 2017. All patients met the Milan criteria and had pathologically confirmed MVI after the first hepatectomy. Based on physician recommendations and patient preference, they were divided into two groups: the RFA group and the RFA combined with sorafenib group (RFA-S group). Patients in the RFA-S group started oral sorafenib (400 mg bid) one month after RFA and continued until disease progression or intolerable toxicity, with a maximum treatment duration of 2 years. Overall survival (OS) and tumor-free survival were compared between the two groups. Subgroup survival analysis was performed, and risk factors were assessed using Cox multivariate analysis.Results There was no significant difference between RFA and RFA-S groups at baseline (P>0.05). The 5-year overall survival rate and tumor-free survival rate were respectively 46.2% and 28.6% in RFA-S group, significantly higher than those in the RFA group (23.3% and 11.0%) (P=0.004 8, P=0.001 8). Patients with an ablation safety margin ≤0.5 cm showed more significant DFS benefits from combined therapy with sorafenib (HR=0.46, 95% CI: 0.27-0.78, P=0.004 1). Multivariate analysis showed that multiple tumors, recurrence interval ≤2 years, and RFA monotherapy were independent risk factors for poor prognosis.Conclusions RFA combined with sorafenib is more effective than RFA alone for RHCC patients with MVI, and can improve the survival outcome of such recurrent patients.