Surgery for rectal cancer beyond the mesorectum: Indications, preparation, limits, and results

Pelvic exenteration (PE) is a potentially curative surgical option for patients with locally advanced rectal cancer (LARC) orlocallyrecurrent rectal cancer (LRRC) involvingmultivisceralstructures. Originally conceived as a palliative procedure, advancements in surgical techniques and multidisciplinary management have broadened its indications, enabling R0 resections in over 60% of cases. Appropriate patient selection, based on advanced imaging and comprehensive functional assessment, is essential to optimize oncologic outcomes. Currently, the surgical indication is primarily determined by the reasonable possibility of achieving an R0 resection with acceptable morbidity in a suitable candidate, which may translate into high survival rates. Surgical planning should follow a compartmental approach and require close collaboration among colorectal, urologic, gynecologic, vascular, orthopedic, plastic, and reconstructive surgeons. Urinary, gynecologic, vascular, osseous, and soft tissue reconstructions are tailored to the tumour’s extent and the patient's individual needs. In selected cases, PE may be performed with palliative intent. Intraoperative radiotherapy (IORT) and minimally invasive approaches have emerged as valuable adjuncts. Long-term oncologic and functional outcomes are closely linked to the achievement of negative margins. While postoperative morbidity remains significant, mortality rates have declined in high-volume centres. Postoperative quality of life has become a key outcome, with increasing emphasis on patient-reported outcome measures (PROMs) to guide clinical decision-making. PE continues to challenge traditional limits of resectability, offering renewed hope to carefully selected patients.