Uterine leiomyosarcomas are rare diseases but represent the commonest subtype of uterine sarcomas. For patients with early-stage localized disease, it is well-known that surgery is the most important part of treatment. However, approximately 40% of patients will present recurrent disease with distant metastasis, and for these patients the question arises as to whether they should have secondary cytoreductive surgery or systemic therapy alone. Decision making needs to take various factors into consideration, as only carefully selected patients will benefit from surgery. Patients for whom surgery is most likely to be beneficial are those with small-volume metastatic disease and late recurrences. In contrast, patients with rapidly progressive disease, or those for whom surgery will not achieve complete macroscopic removal, are unlikely to benefit from surgery, which should be avoided.