Allogeneic hematopoietic stem cell transplantation is well accepted as a curative treatment approach for younger patients with myelodysplastic syndrome (MDS) and has become one of the most frequent indications for allogeneic stem cell transplantation as reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). However, MDS patients are usually elderly with a median age of about 75 years at diagnosis. Large register studies have confirmed the feasibility of the procedure in elderly MDS patients and in the register of the European Group for Blood and Marrow Transplantation (EBMT) 1/3 of the allogeneic transplant procedures for MDS were performed in 2010 in patients aged > 60 years. Despite its curative potential, its role in the treatment of elderly MDS patients is less defined. Because of the inherent complications of the transplantation leading to treatment-related mortality and the risk of relapse, a careful calculation of the benefit for each patient is mandatory, taking into account comorbidities, disease status, donor selection, and effective non-transplant therapies. Prospective multicenter studies are needed to define optimal intensity of the conditioning regimen, timing of transplantation within a treatment algorithm including drug-based therapies and post-transplant strategies to reduce the risk of relapse.