Surfactant replacement therapy is an established component of the management of neonatal respiratory distress syndrome. In Libyan tertiary neonatal intensive care units, Survanta (Beractant) and bovine lipid extract surfactant (BLES) are commonly used natural bovine surfactant preparations. To compare clinical outcomes, respiratory support requirements, selected complications, and duration of hospitalization among neonates treated with Survanta or BLES at two Libyan medical centers. This retrospective comparative cohort study was conducted at Benghazi Medical Center and Misurata Medical Center (August 2024 to August 2026). A total of 610 medical records of neonates who received surfactant therapy were reviewed. After excluding 102 records because of incomplete documentation, 508 neonates were included in the final analysis: 228 in the Survanta group and 280 in the BLES group. Data included demographic characteristics, baseline arterial blood gas findings, post-treatment respiratory support, selected procedural and clinical complications, duration of hospitalization, and survival outcomes. Hyaline membrane disease was the most common indication for surfactant therapy, accounting for 88.8% of the cases. There are no differences were observed between the Survanta and BLES groups in mechanical ventilation requirement, CPAP requirement, pneumothorax, bronchopulmonary dysplasia, or survival outcome. Compared with the Survanta group, a greater proportion of neonates in the BLES group had a NICU stay of seven days or longer (66.7% vs. 33.3%, p=0.002), a total hospital stay of 7 - 14 days (67.5% vs. 32.5%, p=0.001), and nosocomial sepsis (60.2% vs. 39.8%, p=0.019). Procedural bradycardia (54.1% vs. 45.9%, p=0.001), oxygen desaturation (50.2% vs. 49.8%, p=0.018), and intraventricular hemorrhage (63.6% vs. 36.4%, p=0.025) were more frequently observed in the Survanta group, whereas post-instillation systemic hypotension was more frequently observed in the BLES group (61.3% vs. 38.7%, p=0.001). Thus, Survanta and BLES showed no differences in the primary respiratory and survival outcomes examined. Differences were observed in the duration of hospitalization, nosocomial sepsis, and selected procedural and clinical complications.