Background: The aim of this study was to compare survival outcomes, short-term post-operative morbidity and mortality in patients undergoing primary debulking surgery (PDS) and receiving neoadjuvant chemotherapy (NACT). Methods: This study is a single center retrospective clinical study. We evaluated 196 patients with advanced stage epithelial ovarian cancer (EOC). The treatment approach was based on the patient’s performance status (PS), preoperative radiological evaluation and diagnostic laparoscopic evaluation. Overall survival (OS) and progression-free survival (PFS) were compared for stage III–IV and IIIC alone according to the amount of residual tumor which determines the prognosis. Kaplan-Meier method was used for survival curves and Long-Rank test was used for survival comparisons. Pearson Chi-square test was used to compare categorical variables. Results: Out of 196 patients, 127 (64.7%) underwent PDS and 69 (35.2%) received NACT due to the comorbities, poor PS and unresectable tumor burden. In both groups most of the patients had stage IIIC and serous histology. NACT group had significantly older age, poorer PS, higher rates of recurrence and mortality. Complete and optimal cytoreduction were similar in both groups (PDS: 43.3% and 40.2% versus NACT: 33.3% and 50.7%, respectively). Complete resection was observed to prolong PFS and OS in PDS. In patients with stage IIIC, the effect of PDS on OS is superior. Because of the low number of patients in stage IVA–B, OS and PFS were found insignificant in both groups. The 30-day post-operative complication rate was higher in the NACT group (p < 0.001). Conclusions: PDS should be preferred initial treatment for patients with III–IV EOC. NACT should be considered for patients who are not medically fit for surgery and/or for whom complete cytoreduction is not feasible.