Objectives: The purpose of the present study was to retrospectively compare the outcomes of video-assisted thoracic surgery in awake and anesthetized patients in the treatment of secondary spontaneous pneumothorax. Methods: A total of 57 consecutive patients who underwent video-assisted thoracic surgery for secondary spontaneous pneumothorax was retrospectively analyzed. Of these patients, 15 underwent surgery under epidural and/or local anesthesia (ELA) and 42 under general anesthesia. Using propensity score matching, we identified comparable patient groups: the ELA group and general anesthesia group (n = 8 each). We compared the duration of operating room stay, operating time, postoperative hematologic data on postoperative day 1, postoperative complications, duration of hospital stay, and the incidence of hospital death between the ELA and general anesthesia groups. Results: After propensity score matching, the duration of operating room stay was significantly shorter in the ELA group (P = .006). The incidence of postoperative respiratory complications, including pneumonia and acute respiratory distress syndrome, was lower in the ELA group (P = .02). The duration of postoperative hospital stay and the incidence of hospital death were not different between the 2 groups. Conclusions: The ELA group had a lower incidence of postoperative respiratory complications. Awake video-assisted thoracic surgery can be performed with an acceptable overall morbidity for patients with secondary spontaneous pneumothorax.