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In the process of urbanization, water bodies bear considerable anthropogenic pressure, resulting in a reduction of their surface area in most instances. Nevertheless, in contrast to many other regions, the Lixiahe region in Jiangsu Province, located in China’s eastern plain, has experienced a continuous expansion of water bodies over the past few decades amid rapid urbanization. Using Landsat images spanning from 1975 to 2023, this study analyzed changes in water resources and the growth of impervious surfaces during urbanization. The findings revealed that the area of impervious surfaces in the region increased from 227.1 km² in 1975 to 1883.1 km² in 2023. Natural wetland suffered significant losses, declining from 507.2 km² in 1975 to near disappearance by the year 2000, with no significant recovery observed thereafter. Simultaneously, the water area expanded from 459.3 km² in 1975 to 2373.1 km² in 2023, primarily propelled by the significant contribution of aquaculture ponds, accounting for 2175.0 km² or 91.7% of the total water area. Driver analysis revealed that these changes were found to be influenced by factors such as population, economy, demand, and policies. However, alongside the economic development brought by urbanization, negative impacts such as lake shrinkage, eutrophication, and increased flood risks have emerged. The Lixiahe region, as a relatively underdeveloped part of Jiangsu Province, faces the challenge of striking a balance between economic growth and environmental conservation.