Resection of the petrous temporal bone to various degrees provides different levels of access to lesions of the posterior fossa. Although their nomenclature can be confusing, the numerous variants of the transpetrosal approaches can be classified broadly into anterior and posterior groups. The posterior transpetrosal approaches include the retrolabyrinthine, translabyrinthine, and transcochlear, whereas the ones in the anterior group are extensions of the basic middle fossa approach. Both the anterior and posterior approaches have the potential of exposing the cerebellopontine angle and the petroclival region. The posterior approaches are based on the standard mastoidectomy and involve resection of the petrous bone to various degrees. This results in progressively increased exposure anteriorly, but comes at the expense of hearing in the translabyrinthine approach and of hearing and facial strength in the transcochlear approach. In contrast, the middle fossa approaches spare the lateral petrous bone and involve resection of the medial petrous bone to various degrees. All of the middle fossa approaches are designed to preserve hearing. Extensions of the middle fossa approaches involve resection of bone within the Kawase rhomboid and division of the tentorium to provide exposure of the posterior fossa.