The need to preserve hearing during acoustic neuroma removal has rekindled interest in labyrinth-sparing procedures. This review of 11 years' experience with the retrosigmoid approach to acoustic neuroma removal includes 335 procedures in 332 patients. There were no intraoperative deaths; two patients died in the postoperative period. The facial nerve was preserved in 86.3% of procedures, and auditory function was preserved in 45 procedures (34% of those tumors were 2 cm or smaller). Postoperative complications occurred in 101 procedures, the most common being cerebrospinal fluid otorhinorrhea in 40 cases; 25 of these required secondary surgery. Meningitis occurred 16 times and aspiration 8 times; all other complications were less frequent. Tumor removal was incomplete in eight procedures; in only one of these cases has tumor recurred. The six recurrences usually were identified 5 or more years postoperatively. This has prompted us to follow patients for 7 years postoperatively. Major changes in our management include the use of the supine position and of electrophysiologic monitoring. Advantages of the approach are: (1) wide access to the tumor, (2) applicability to all tumor sizes, (3) potential to preserve facial and auditory function in all cases, and (4) ability to change procedure without sacrificing labyrinth. This review confirms our confidence in this approach to acoustic neuroma removal.