The purpose of this study is to investigate if initial occurrences of primary spontaneous pneumothorax (PSP) should be included in the indication for video-assisted thoracoscopic surgery (VATS) for their treatment. The goal of this study was to compile our findings in order to determine whether VATS is appropriate at the beginning of a new PSP. Methods: This retrospective comparison cohort study included 67 patients consecutive with newly diagnosed PSP. Patients were separated into two groups in this study according to the therapeutic intervention they underwent. While the second group (33 patients) underwent VATS, the first group (34 patients) underwent pleural drainage. The following variables were examined: (1) lengthy air leaks (>48 hours); (2) pleural drainage time; (3) length of hospital stay; and (4) recurrences. Results: Both groups did not have any postoperative complications, with the exception of protracted air leaks, which occurred in eight (23.5%) of the first group's patients and one (3%) of the second group's patients. In comparison to 3.5 0.1 and 4.3 0.2 days in the second group, the mean SD time for drainage and hospitalization in the first group was 6.4 0.2 and 8.2 0.6 days, respectively. During follow-up (median 13.2 months), recurrences occurred in 15 patients (44.1%) in the first group, but just one (3.3%) in the second. In contrast, all metrics showed statistically significant differences between the two groups (P 0.05). As evidenced by its safety, shorter hospital stay, and extremely low recurrence rate, the use of VATS for first-time PSP is justified.