Oncovascular Resection in Pelvic Exenteration: A Systematic Review

BACKGROUND: Resection of major vascular structures may be required to achieve R0 resection in pelvic exenteration surgery for advanced pelvic malignancy. The evidence base for pelvic oncovascular techniques is limited, with patient outcomes following these procedures not widely reported. OBJECTIVES: This systematic review synthesises the current literature on R0 resection and 30-day mortality rates following oncovascular pelvic exenteration. METHODS: A systematic review was conducted according to a pre-defined protocol (PROSPERO ID CRD42024613055). MEDLINE, EMBASE, Cochrane Library and Web of Science were interrogated between January 1, 1947, to July 1, 2025. Studies exploring oncovascular resection in advanced pelvic malignancy were considered. Pre-1980 studies were included narratively but excluded from quantitative synthesis. Data were extracted on R0 resection, postoperative morbidity and mortality. The ROBINS-1 V2 tool was used to assess bias. RESULTS: Seventeen studies met the inclusion criteria. After excluding three pre-1980 studies, 411 contemporary patients were included in quantitative analysis. Among curative-intent procedures (n = 334), the R0 resection rate was 65.3% (218/334). With regards to morbidity, Clavien-Dindo grade I-II complications occurred in 56.9% (227/399) and grade III-IV complications in 28.5% (109/382). Thirty-day mortality was 1.9% (8/411). Median overall survival was 41 months (range 34-57.6), with median disease-free survival of 27 months (range 8-43.2). CONCLUSION: Approximately two thirds of patients undergoing oncovascular pelvic exenteration achieved R0 resection, with morbidity and 30-day mortality of 1.9%. Outcomes remain inferior to contemporary benchmark series for conventional exenteration, reflecting the pioneering phase of oncovascular practice. Centralisation, rigorous audit and benchmarking and improved patient selection should be the focus of future work to improve R0 and complication rates.