Concomitant chemo-radiation followed by brachytherapy, for the treatment of locally advanced cancer, is considered as the standard of care in many countries. The place of “adjuvant” hysterectomy to remove potential residual disease after the end of radiation therapy fuels a lot of debates during the three last decades. But using modern technics of external radiation therapy and brachytherapy (3D image-guided adaptive procedure) the rate of patients with residual disease is low (<10%) and the morbidity of hysterectomy in this previously irradiated area consistent. As randomized trial failed to demonstrate a survival improvement of such hysterectomy, many teams considered this procedure as useless and obsolete. Such surgery could be nevertheless considered in patients having “really” a residual disease at the end of treatment but such cases should be highly selected to ensure the absence of extra-cervical disease in these patients having chemo-radio-resistant disease with a higher risk of extra-pelvic occult spread.

Although cancer usually affects aged population, invasive gynecological tumors can occur during reproductive age. Long-term survival rates after gynecological cancer are improving and preservation of fertility has logically become a major issue.

In gynecologic oncologic surgery, there has been gradual development of fertility-saving surgery (FSS) with the aim of preserving the reproductive organs. Survival should not be compromised and thus indications are restricted to patients of a young age with a desire to preserve fertility and presenting with a well-differentiated cervical, ovarian, or endometrial low-grade tumor in its early stages or with low malignant potential.

In this chapter, we discuss indications for FSS in women with gynecological cancer, according to oncological and reproductive outcomes.