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We aim to investigate the factors associated with recurrent disease following surgery for primary acquired attic cholesteatoma. We hypothesize that minimal invasive, mucosal sparing operation techniques have beneficial effects on the outcome in terms of recurrence.Retrospective study.Tertiary referral center.A total of 110 patients presenting with primary acquired attic cholesteatoma were enrolled in the study. Patients undergoing revision surgery or a canal wall down procedure, as well as patients with residual disease were excluded from the study.During follow-up recurrence was assessed and classified into normal, self-cleaning retraction pockets, or recurrent cholesteatoma requiring revision surgery.We observed during follow-up statistically significant decrease (p = 0.036) in the occurrence of retraction pockets and recurrence in patients operated by the transcanal endoscopic approach (n = 55, 11% re-retraction, 9% recurrence) compared with those who underwent a canal wall up procedure (n = 55, 16% re-retraction, 22% recurrence). However, the multivariate model did not demonstrate statistically significant predictors regarding the outcome. Moreover, the preservation or direct reconstruction of the ossicular chain had a beneficial effect on the outcome. We observed 11% re-retraction and 9% recurrence in cases with preserved or reconstructed ossicular chain versus 18% re-retraction and 24% recurrence (p = 0.011) in cases of nonpreserved or non-reconstructed ossicular chain. A score was established according to the intraoperative mucosal damage and correlated to the occurrence of recurrence (p = 0.02). The risk of recurrence increased by 23.6% (95% confidence interval: 3.22–48.1) with each additional mucosal damage site.Transcanal endoscopic approaches that preserve the mastoid may play an important role in preventing recurrence and underscores the importance of the mucosa and mastoid air cells on middle ear homeostasis.