The reported incidence of uterine perforation in tandem & ovoid brachytherapy ranges from 2 to 10%. Perforation not only potentially increases short term infection risk but treating a tandem in extrauterine or in a false myometrial passage may increase the risk of late rectal or sigmoid complications. When identified at the time of simulation, the brachytherapy may be cancelled, the apparatus removed, and antibiotics started with a subsequent low risk of infection. However, with modern HDR plan optimization, another option may be to treat before device removal if satisfactory dosimetry is achievable since the patient has already accrued the risks of a perforation. Between 2009-2016, 407 tandem & ovoid and 3 tandem & interstitial procedures were performed in 103 patients with cervical cancer. Procedures where the tandem perforated the uterus or created a false passage were identified from the simulation CT scans. HR-CTVs were retrospectively contoured in order to compare V100, D100, D90, rectal Dmax, and sigmoid Dmax doses between insertions with or without perforations and for patients with tandem false passages. Uterine perforations were identified in 12 insertions (2.9%) of which 9 (in 6 pts) were treated before removal. Tandem myometrial false passages without perforation were identified in 20 insertions (5%) in 4 pts all of whom were treated. Median follow up for all patients was 18 months (5 – 69). No acute complications and only 2 late GI toxicities occurred (1, Gr 2 and 1, Gr 3, both from false passage cases). At last follow up, there was 1 pt (10%) with local failure, 1 pt (10%) dead of metastases, 1 (10%) alive with metastases, and 7 (70%) alive without disease. For the 6 patients who had insertions with (9) and without (13) perforations, dosimetry for perforation vs. non-perforation insertions was: V100 74.5% (54 – 97) vs. 86.7% (66 – 100), D100 2.9 Gy (1.8 – 3.4) vs. 3.9 Gy (2.7 – 6.1), D90 4.7 Gy (3.1 – 6.1) vs. 6.2 Gy (3.8 – 9.6), rectal Dmax 3.7 Gy (1.6 – 6.6) vs. 3.8 Gy (2.4 – 5.1), and sigmoid Dmax 9.5 Gy (5 – 14) vs. 9.3 Gy (5.1 – 22). There were no statistically significant differences between the V100, D100, D90, rectal, and sigmoid doses between the insertions with and without perforations. For the false passage insertions (20 in 4 patients): V100 84.4% (66 – 99), D100 3.4 Gy (2.2 – 5.4), D90 5.6 Gy (3.8 – 8.8), rectum Dmax 3.7 Gy (2.1 – 4), and sigmoid Dmax 7.2 Gy (5.4 – 10). Routine abandonment of malpositioned tandem and ovoid brachytherapy insertions may not be necessary. Acute toxicity following uterine perforation is low. Moreover, in selected cases, optimized dosimetry may make possible comparable target volume coverage and normal tissue sparing despite perforating or malpositioned tandems.