The results of 50 cases of vestibular schwannoma surgery with hearing preservation performed by the retrosigmoid approach at Addenbrooke's Hospital, Cambridge, during a 10-year period are presented. The hearing-preservation rate, using audiometric criteria set by others as "serviceable hearing" (Wade PJ, House W. Otolaryngol Head Neck Surg 1984;92:1184-93; Silverstein H, et al. Otolaryngol Head Neck Surg 1986;95:285-91; Cohen NL, et al. Am J Otol 1993;14:423-33) was 8% (4 of 50 cases). When the more stringent selection criteria of near-normal hearing and reporting criteria of socially useful hearing preservation (pure-tone average < 30 dB/speech discrimination score > 70%) is used, the hearing-preservation rate is 4.8% (1 of 21 cases). The only preoperative factor that may predict a favorable hearing-preservation outcome is normal auditory brain stem response morphology (Fisher's exact 2-tailed test, P < 0.001). The number of suitable candidates for hearing-preservation surgery are few. Reasonable indications for attempted vestibular schwannoma surgery with hearing preservation are discussed.