Robotic pelvic exenteration for rectal cancer: a systematic review of an evolving field in complex pelvic surgery

Introduction

Background

Pelvic exenteration is a radical procedure reserved for patients with locally advanced or recurrent rectal cancer involving adjacent pelvic structures. Historically, this operation was considered palliative, but with advances in surgical techniques and multimodal therapies, it is now increasingly performed with curative intent in well-selected patients (1). Pelvic exenteration involves the en-bloc resection of multiple pelvic organs to achieve complete oncological clearance. However, due to its complexity and variability across institutions and specialties, terminology and classification have lacked standardization. To address this, the United Kingdom Pelvic Exenteration Network (UKPEN) developed the Pelvic Exenteration Lexicon, providing a structured framework for documenting surgical components. This consensus defines conventional pelvic exenteration as the removal of most or all pelvic organs, while high-complexity pelvic exenteration extends to include bony structures (e.g., sacrum, pubic bones) and/or pelvic sidewall structures (e.g., major vessels, sciatic nerves) (2). More precisely, Quyn et al. defined pelvic exenteration as the resection of the primary tumour as well as two or more adjacent organs and/or major bone or neurovascular structures (3). The resection must involve a minimum of the three of five pelvic compartments divided anatomically into anterior, central, posterior, left lateral and right lateral compartments (3,4). Multi-visceral resections for locally advanced rectal cancers often fail to meet these criteria but have been labelled in the literature as pelvic exenteration surgery. With the increasing adoption of minimally invasive techniques, including laparoscopic and robotic approaches, the definition of pelvic exenteration is likely to evolve to reflect these advancements.

Rationale and knowledge gap

Traditionally, the approach in any maximally invasive abdominal and pelvis surgery has been open. The mainstay for an open approach is to ensure adequate exposure and therefore obtain negative microscopic margins (R0 resection margin). It has been hailed as the “holy grail” of exenteration surgery when achieving an R0 resection margin as it has been associated significantly with both improvement in survival and quality of life (5,6). In recent years, there has been a growing interest in minimally invasive techniques, including robotic approaches, for complex oncological procedures including cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Early evidence suggests that these approaches are feasible for select, but not all patients (7). One key advantage of minimally invasive surgery in highly complex abdominal procedures is the reduction of laparotomy related morbidities such as abdominal wall failures, wound dehiscence, incisional hernias, post operative pain, intestinal ileus and overall increased length of stay (7,8). For pelvic exenteration specifically, robotic surgery offers several advantages, including enhanced visualization, improved ergonomics, and greater precision when operating in the confined space of the pelvis (9,10). The magnified view provided by robotic platforms is particularly beneficial when meticulous dissection is required to preserve key pelvic structures, such as nerve plexuses, which can impact postoperative functional outcomes (11).

The advantages of robotic surgery can also significantly influence the total mesorectal excision (TME) approach in rectal cancer surgery (12). Modern robotic platforms provide high-definition three dimensional visualisation, allowing for precise identification of anatomical structures and finer dissection within the TME embryonic planes (13). Whilst a robotic approach to the TME dissection for rectal cancer has been widely adopted, its role in pelvic exenteration has been less established (12). Current trends demonstrates that robotic surgery for TME dissection is oncological safe compared to their open and laparoscopic counterparts with a potential for improved functional outcomes (14). However, existing studies on robotic pelvic exenteration have primarily focused on non-colorectal malignancies, such as gynaecological and urological cancers, where the extent of resection varies depending on the pelvic structures involved (15,16). The use of robotics for locally advanced rectal cancer presents unique perspective on this approach compared to other tumours, particularly due to the complexity of the TME plane and the difference in tumour biology.

Objective

This systematic review aims to evaluate the current status and outcomes of robotic pelvic exenteration in rectal cancer patients, synthesising the available evidence in the literature. We present this article in accordance with the PRISMA reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-36/rc).

Methods

Search strategy

A comprehensive literature search was performed using MEDLINE, Embase, PubMed, and Google Scholar from database inception (1974) to December 2024. No protocol was registered for this systematic review. Search terms were combined using Boolean operators. A combination of Medical Subject Headings (MeSH) terms and free-text keywords were used. No language restrictions were applied. Additionally, reference lists of included articles and relevant systematic reviews were manually searched to identify any studies not captured in the database searches. Table S1 outlines the search strategy in detail.

Pelvic exenteration: “Pelvic Exenteration” OR “Total Pelvic Exenteration” OR “Extended Pelvic Resection” OR “Radical Pelvic Surgery” OR “Multi-visceral Resection”

Robotic Surgery: “Robotic Surgery” OR “Robotic-Assisted Surgery” OR “Robotic-Assisted Procedures” OR “Robotic-Assisted Laparoscopy” OR “Robotic System” OR “Minimally Invasive Surgery”

Colorectal Cancer: “Colorectal Cancer” OR “Colorectal Neoplasm” OR “Colorectal Carcinoma” OR “Rectal Cancer” OR “Rectal Neoplasm” OR “Colonic Neoplasm” OR “Advanced Colorectal Cancer” OR “Locally Advanced Rectal Cancer” OR “Recurrent Rectal Cancer”

Inclusion and exclusion criteria

The following inclusion criteria were applied: only studies reporting on robotic pelvic exenteration for colorectal cancers were included. Articles that included other malignancies (e.g., gynecologic, urologic) without rectal cancer-specific data were excluded. Studies describing multi-visceral resections that did not meet the defined criteria for pelvic exenteration were excluded. Given the novelty of this approach, we included case reports and small case series with sufficient outcome data but excluded video vignettes that did not provide sufficient details of the patients’ outcomes. Patients that were likely from the same database the most updated database of patients were used.

Literature screening and data extraction

Two authors (E.C. and K.G.) independently screened articles retrieved in the systematic literature search. Pre-determined eligibility criteria were applied to evaluate potential studies for inclusion. Once all titles and abstracts had been screened, the full text of all articles were again independently assessed by the two authors. Whenever there was a disagreement, a third author (A.Z.) was consulted to reach a consensus. The reference list of screened article were also reviewed to identify any additional eligible studies meeting the inclusion criteria. Where studies presented mixed data (e.g., pelvic exenteration for various malignancies or combined data with multi-visceral resections), only the specific outcomes were extracted and included when clearly distinguishable. Otherwise, the aggregated data were used for analysis. When necessary, data were collated or converted to a consistent format for synthesis, and missing summary statistics were noted but not imputed.

Outcomes measured

The primary objective of this study was to assess the feasibility of the robotic approach for pelvic exenteration (defined by Burns et al. and Quyn et al.) (2,3). To achieve this, our primary outcomes focused on operative measures, including conversion rates (to open or laparoscopic surgery), operative time, and estimated blood loss.

Our secondary outcomes evaluated postoperative recovery and oncological effectiveness. These included postoperative complications, length of hospital stay (LOS), and functional outcomes. Oncological outcomes were assessed through R0 resection rates, overall survival, and, where available, disease-free survival.

Study quality assessment

The methodological quality of the included studies was assessed using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies or for Case Series Studies, as appropriate (17). Two reviewers (E.C. and K.G.) independently conducted the quality appraisal, with discrepancies resolved through discussion or adjudication by a third reviewer (A.Z.). Overall quality ratings (Good, Fair, or Poor) and individual item assessments are summarised in Table 1.

Synthesis of results

Due to significant heterogeneity in study designs, patient populations, procedural details, and outcome reporting, a quantitative meta-analysis was not feasible. Therefore, a systematic review with narrative synthesis was performed.

Results

A total of 15 studies were identified and the search and selection process are presented in Figure 1. A total of eleven retrospective observational studies (19-24,26,28-31) and four case reports (9,18,25,27) were included, involving heterogeneous patient populations undergoing robotic surgery for rectal cancer. Many studies included patients who underwent multi-visceral resections that did not strictly meet the criteria for pelvic exenteration. For these studies, we extracted, where possible, patients who underwent pelvic exenteration as outlined by the criteria in this review. Expectedly, the sample sizes were generally small ranging from 1–168, with most studies being single-institution experiences. The largest study, conducted by Khan et al. (2024), was a multi-centre study that included 168 patients, and incorporated the “Pelvic Exenteration Lexicon” for standardised reporting (30). Although reported in this format, it was unclear whether all patients included in the study met the definition of pelvic exenteration as applied this review. Overall, the quality of the studies ranged from poor to fair which is consistent with the novel nature of this procedure and approach.

Figure 1 PRISMA flow diagram for the study selection process for the systematic review of robotic pelvic exenteration. *, six articles were excluded for multiple reasons; therefore, the sum of reasons exceeds the number of excluded articles.

All studies utilised a version of the Da Vinci robotic system (Intuitive Surgical Inc., Sunnyvale, USA) for surgical procedures. The complexity of pelvic exenteration performed varied across studies, with most reporting terminologies such as total, posterior and anterior pelvic exenteration. Only one study used the “Pelvic Exenteration Lexicon” (30) and with most studies including patients who underwent variations of multi-visceral resections that did not meet the extent or complexity of what Quyn et al. defined as a pelvic exenteration (3).

Operative outcomes

Overall, there were nine cases reported to require conversion to open surgery with no studies providing a reason for conversion. Operative times varied significantly across studies ranging from a time of 306 to 900 minutes. This likely reflects institutional differences in surgical experience and patient complexity as well as the learning curve associated with use of the robot in complex procedures. Estimated blood loss ranged widely (100 to 4,000 mL), with some studies suggesting reduced intraoperative blood loss compared to traditional open pelvic exenteration (20,24).

Post operative outcomes

The overall LOS was reported inconsistently and showed variability, but most studies suggested a shorter recovery period with robotic-assisted approaches compared to historical open cohorts. Postoperative complications (Clavien-Dindo Grade III+) were reported in several studies, though the incidence varied depending on patient selection and procedural complexity. Overall, complication rates ranged from 20.5% to 40%, comparable to those reported for open pelvic exenterations (24). The most commonly reported complications included anastomotic leaks, pelvic sepsis, and thromboembolic events. Only one study, by Heah et al., specifically reported on functional outcomes, noting that one patient experienced low anterior resection syndrome (19).

Oncological outcomes

Achieving a negative microscopic margin (R0 resection) was a key oncological outcome assessed across all the studies. While most reported high R0 resection rates, the limited sample sizes and high likelihood of super selection in patients significantly restrict definitive conclusions. Most of the reported R0 resection rates were collated with patients who underwent less complex resections that did not meet the definition of pelvic exenteration described in this review.

Overall survival and disease-free survival were infrequently reported, with most studies lacking long-term oncological follow-up. However, where available, survival data suggested that robotic pelvic exenteration may offer comparable oncological outcomes to other approaches, however there were no studies provided directly compared the two groups. Kumar et al. compared two-year disease-free survival between minimally invasive (laparoscopic and robotic cases) with open pelvic exenteration and found no significant difference (20).

Discussion

Summary of results

This systematic review highlights the expanding body of literature on robotic surgery, particularly in the context of pelvic exenteration. A significant portion of the existing research focuses on multi-visceral resections rather than true pelvic exenterations; resections involving more than three compartments of the pelvis. This pattern reflects tendencies in bias patient selection with new procedure and the associated learning curve; surgeons are likely to preference cases requiring less extensive pelvic dissection and fewer organ removals. High-volume centres specialising in both robotic surgery and exenteration have been the early adopters, predominantly utilising the da Vinci robotic platform. Our findings reveal a marked increase in published literature for this topic over the past 24 months, reflecting the interest and increasing uptake of this approach for rectal cancers. Our review demonstrates the recent outcomes in this emerging field appear promising, with low conversion rates to laparoscopy or open surgery and comparable R0 resection rates. While robotic surgery demonstrates advantages in reducing overall length of stay and blood loss compared to open surgery, direct comparisons with laparoscopic approaches remain limited (24). Complication rates are similar across techniques, but long-term data are scarce, and existing results are likely influenced by selection bias, given the careful patient selection for robotic procedures (20,24).

Early definitions of pelvic exenterations, prior to the “Pelvic Exenteration Lexicon” consensus, often included patients who had less extensive multi-visceral resections in the pelvis (32). These included cases such as abdominoperineal excision of the rectum and prostatectomy, which are examples of less extensive resections. Results from such resections were favourable with Chang et al., reported a series of 46 patients with variable extent of their resections achieving high rates of R0 resections and only one case requiring conversion to open. By including simpler cases, the study presents an overly optimistic portrayal of robotic pelvic exenteration outcomes, which may mislead surgical decision-making regarding its feasibility, safety, and oncological efficacy in more complex cases (2). This review attempted to exclude these cases and attempted to collate the outcomes of patients who underwent robotic procedures that removed most or all of the pelvic organs. We emphasise the need for comparisons across studies and recommend future research should adopt the Pelvic Exenteration Lexicon as a standardized framework and Quyn et al.’s definition, particularly when evaluating minimally invasive approaches (2,3). Standardising definitions will reduce variability, enhance the comparability of outcomes, and support the development of guidelines and patient selection criteria for robotic pelvic exenteration (2,33). Such consistency is crucial for optimising surgical decision-making and fully defining the role of robotic-assisted techniques in complex pelvic resections. As the adoption of robotic pelvic exenteration continues to grow, it is essential to critically evaluate its advantages over traditional open and laparoscopic approaches that it can offer.

Advantages of robotic pelvic exenterations

Early reports on robotic pelvic exenterations were performed with the intention of overcoming the deficiencies in the laparoscopic counterparts such as two-dimensional vision, poor ergonomics and limited dexterity with laparoscopic instruments (9,10). Similar to the robotics role in other procedures requiring TME dissections, the robot improved precision with preserving autonomic pelvic nerves as well as allowing for greater precision when dissecting the often locally advanced rectal tumour that may breach the usual anatomical planes during a pelvic exenteration. Patients with locally advanced or recurrent rectal cancer often have had previous radiation or complex anatomical distortion with dense adhesions from their malignancy or previous pelvic surgery, these are obscure critical structure and made be difficult for precise tissue differentiation (34). Studies such as Watanabe et al. and Kumar et al. have highlighted the benefits of articulating robotic instruments, which surpass the dexterity of conventional laparoscopic tools, allowing for meticulous nerve preservation and improved haemostasis in deep pelvic dissection (20,35). The tremor filtration and improved dexterity of robotic instruments allow for more controlled dissection around major neurovascular bundles, potentially reducing inadvertent injury and minimizing blood loss. Robotic systems potentially allows for greater precise en bloc resection of involved structures—particularly in situation where there is obliteration of the normal plane, ensuring a greater opportunity to achieve R0 resection (26). Moreover, the integration of indocyanine green (ICG) fluorescence imaging into robotic platforms can enhance intraoperative visualisation (Figure 2). ICG allows for real-time identification of critical structures such as ureters, blood vessels, and bowel segments, and reduces the risk of inadvertent injury (36). For example, intraureteral injection of ICG enables fluorescent visualisation of the ureters, facilitating safe dissection even in the presence of dense adhesions or distorted anatomy (37).

Figure 2 Intraoperative image using indocyanine green fluorescence to evaluate vascular perfusion of the bowel in the robotic setting.

Pelvic exenteration often requires several hours of operative time, depending on complexity. A key advantage of robotic surgery is its ergonomic benefits, which significantly reduce surgeon fatigue and enhance operative endurance. By allowing the surgeon to operate in a seated, ergonomically optimised position, robotic platforms minimise the need for excessive wrist, shoulder, and arm movements, which are common sources of strain in conventional open or laparoscopic approaches. This benefit also extends to the surgical assistants, as the robotic system eliminates the need to hold a laparoscopic camera for prolonged periods. In the long term, the reduced physical toll on the surgeon may help prolong career longevity (38). Overall, the minimisation of fatigue in prolonged and complex surgeries, may contribute to improved precision, reduced intraoperative errors, and enhanced overall efficiency, ultimately leading to better surgical outcomes.

Why perform minimally invasive techniques for maximally invasive surgery

Minimally invasive techniques offer significant advantages when performing maximally invasive surgeries such as pelvic exenteration. While the procedure itself involves extensive organ resection, a robotic approach can minimise abdominal incisions, leading to faster healing, reduced postoperative pain, and a lower risk of wound complications (39). Unlike other robotic abdominal procedures, such as robotic colorectal resections, where a large abdominal extraction site can negate the benefits of minimal access, pelvic exenteration utilises a natural perineal extraction site. This maintains the advantages of a minimally invasive approach keeping abdominal incisions minimal (40). The sparing of large abdominal incisions, reducing the risk of hernias, dehiscence, and prolonged recovery (39). Furthermore, pelvic exenteration patient often have a history of previous radiation, extensive adhesions, and multiple comorbidities. Minimally invasive approaches may lower intraoperative blood loss, reduce inflammatory response, and preserve immune function, all of which contribute to faster postoperative recovery and earlier initiation of adjuvant therapy if needed (41). Additionally, the robotic platform enhances surgical precision and visualisation, particularly in settings requiring nerve preservation to optimise functional outcomes such as bladder and sexual function (42). Given the high morbidity associated with open surgery, the continued refinement and adoption of robotic techniques for maximally invasive procedures allows for improvement in surgical strategy—one that can potentially enhance oncologic outcomes while simultaneously minimising operative trauma.

Limitations of robotic surgery

The high cost of robotic surgery remains a major barrier to its widespread adoption. The capital expense of robotic platforms, along with ongoing maintenance and instrument costs, significantly limits accessibility, particularly in lower-resource healthcare systems. However, with the introduction of newer robotic platforms, competition may drive costs down, enabling broader adoption as well as improve innovative approaches to robotic surgery (43). Limited access to robotic platforms across many centres, combined with the steep learning curve associated with robotic pelvic surgery, further limits the generalisability of our findings. Another major challenge is the prolonged operative time associated with robotic pelvic exenteration. Given the already lengthy nature of pelvic exenteration procedures, the additional time required for robotic docking and intraoperative instrument changes can be significant. For example, Chan et al. reported a robotic pelvic exenteration case requiring 900 minutes, compared with the significantly shorter median laparoscopic time of 455 minutes (29). When compared with open procedures, this difference is even more pronounced, with Zhuang et al., reporting median operative times of 295 minutes for open posterior pelvic exenterations (11). A key technical limitation of robotic surgery is the lack of haptic feedback (32). Surgeons must rely solely on visual cues to assess tissue tension and handling, which may increase the risk of inadvertent injury to critical structures, especially in fibrotic or irradiated fields. While advanced imaging modalities such as ICG fluorescence can help visualise vascular structures, they do not replace the tactile sensation often crucial in complex dissections. However, as robotic technology continues to evolve, newer platforms incorporating haptic feedback systems are emerging, potentially mitigating this deficiency and improve the precision and safety of robotic pelvic exenteration (44).

Limitations of this review

Our study is limited by the inclusion of primarily case series and case reports, as well as studies that included patients that did not undergo a true “pelvic exenteration”. Many of the studies were comprised of low numbers and single institution data, thus limiting the ability to compare, statistically analyse and draw strong conclusions. While we purposefully excluded some cases to maintain a clearer focus, this also resulted in an even smaller and more heterogeneous dataset.

The heterogeneity of the studies as mentioned previously, is a significant limitation to this review. This variability represents a significant confounding factor in assessing robotic pelvic exenteration outcomes. Patient selection bias remains a key consideration; patients chosen for robotic-assisted surgery are often those with less extensive disease, requiring fewer radical resections and possessing more favourable anatomy. This inherent bias may contribute to the relatively favourable oncological and disease-free survival outcomes in the robotic cohort as well as R0 resection rates. Additionally, this factor is also likely to influence perioperative metrics, such as reduced blood loss, shorter operative times, and lower postoperative morbidity. Finally, long-term oncological and functional outcomes remain poorly reported, with most studies focusing on short-term metrics. Functional recovery, including urinary, bowel, and sexual function, is rarely assessed, despite being crucial for patient quality of life. These limitations underscore the need for standardised, prospective studies with comparison to laparoscopic and open to provide more definitive insights into the comparative effectiveness of robotic pelvic exenteration and its long-term oncologic and functional outcomes.

Future

Robotic platforms continue to evolve at a rapid pace, integrating advanced features that significantly benefit pelvic exenteration surgery. One of the most valuable advancements is dual-console capability, which allows multiple surgeons especially from different specialities for pelvic exenterations (e.g., colorectal, urology and gynaecology) to seamlessly alternate or operate together during different phases of the procedure (27). This not only improves the efficiency of the operation and increases the safety of the procedure—allowing surgeons to identify where key structures have been dissected—but it also fosters a collaborative learning environment between surgeons. We have continued to see improvement in the instruments used with haptic feedback (44), increased degrees of freedom and improve stability to allow for greater precision in dissection (45). With new platforms arising, we expect this will drive innovation, accessibility and reduce the learning curve required to perform maximally invasive surgery such as pelvic exenterations (43).

Conclusions

Robotic pelvic exenteration for rectal cancer remains an emerging technique, with current evidence primarily derived from case reports, case series, and retrospective observational studies. Despite the lack of large-scale prospective trials, the available literature suggests that robotic-assisted surgery offers several key advantages, including enhanced ergonomics, superior visualisation, and precise pelvic dissection—particularly beyond the TME plane. These benefits may contribute to improved operative efficiency and postoperative recovery when applied to appropriately selected patients.

While early cases demonstrate high R0 resection rates and comparable oncologic outcomes, the heterogeneity in how pelvic exenteration is defined across studies remains a significant limitation. Standardisation of terminology—such as through the pelvic exenteration lexicon—is essential to ensure that reported outcomes accurately reflect the complexity of these procedures. Future research should aim to establish whether robotic pelvic exenteration is a viable alternative, or even a superior approach, compared to open and laparoscopic techniques. With continued advancements in robotic technology and increasing surgical expertise, robotic pelvic exenteration may evolve into the preferred technique for managing locally advanced and recurrent rectal cancer.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Zi Qin Ng and Zhen Hao Ang) for the series “Robotic Colorectal Surgery” published in AME Surgical Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-36/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-36/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-36/coif). The series “Robotic Colorectal Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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