A retrospective study was performed of the evaluable data in 710 patients with a spontaneous pneumothorax. The male:female ratio was 3.4:1. A thoracoscopy was performed in 622 patients. The two main therapeutic strategies were pleurodesis with talc poudrage (n = 356) and thoracotomy (n = 248). The success rate of talc poudrage was 88 percent, and in the group failures who have undergone surgery afterwards, we found unexpected bullous structures in 20 of 37 patients. The success rate of operation (bullectomy, pleurectomy, or resection) was 97 percent. Our conclusion is that aggressive therapy in spontaneous pneumothorax is acceptable, with a high success rate with very few complications. The diagnostic thoracoscopic evaluation needs to be in experienced hands, especially to inspect the apical lobes with the Valsalva maneuver.