Six Decades of Pelvic Exenterative Surgery for Gynaecological Malignancies: A Meta-analysis of Indications and Surgical Outcomes in 13,434 Cases Across 29 Countries

Background/Aim: Robust international data on pelvic exenteration (PE) are limited. This study aimed to summarise indications, intent, surgical outcomes, morbidity, and mortality of PE for gynaecological malignancies. Materials and Methods: PubMed was searched from inception to November 2024 (PROSPERO CRD42024615187) following PRISMA guidelines. Data on histology, demographics, body mass index, PE type and intent, prior radiotherapy, resection margins, operative time, hospital stay, and Clavien-Dindo (CD) morbidity/mortality were extracted. Random-effects meta-analysis estimated pooled proportions with 95% confidence intervals (95%CI). Exploratory subgroup analyses compared pre- versus post-2005 studies and regions. Study quality was assessed using MINORS. Results: We included 132 studies comprising 13,434 women. Pooled proportions of anterior, posterior, and total PE were 33%, 19%, and 49%, respectively. Indications were cervical (61%), uterine (13%), vulval (13%), and vaginal/other malignancies (17%). PE was performed for recurrent disease in 68%, and negative margins were achieved in 76%. Pooled CD grade I-IV complication rates were 21%, 38%, 28%, and 10%, respectively; 30-day mortality was 5%. From pre- to post-2005 studies, cervical indications declined from 76.1% to 61.0% (p=0.008), uterine indications increased from 3.0% to 12.4% (p<0.001), and mortality decreased from 8.1% to 3.7% (p<0.001). Mortality was 4.5% in Europe, 5.9% in the US, and 11.4% in Latin America (p<0.001). Conclusion: PE carries substantial morbidity, while perioperative mortality was approximately 5% overall and 3.7% in post-2005 studies. Given substantial heterogeneity, pooled estimates should be interpreted as broad descriptive summaries rather than universal benchmarks.