The extent of residual disease following upfront cytoreductive surgery for stage III–IV ovarian cancer is one of the strongest prognostic factors for progression-free and overall survival. Currently, there are two approaches proposed in order to achieve minimal residual disease: primary debulking surgery (PDS) and neoadjuvant chemotherapy (NACT)) followed by interval debulking surgery. In the last decade, the field has developed a greater understanding of both approaches and more importantly, several prospective randomized trials were designed to address the question of which patients are most or least likely to benefit from primary debulking surgery versus neoadjuvant chemotherapy.