Systematic Review and Meta-analysis of Perioperative Outcomes of Minimally Invasive and Open Pelvic Exenteration for Locally Advanced and Recurrent Colorectal Cancer.

BACKGROUND: Pelvic exenteration (PE) is a complex surgery used for locally advanced and recurrent colorectal cancer. With most PE procedures performed via laparotomy, the role of minimally invasive surgery (MIS) in PE remains unclear. This systematic review aimed to assess perioperative outcomes of MI compared to open PE in locally advanced and recurrent colorectal cancer. METHODS: A PRISMA-compliant systematic search of PubMed, Scopus, and Google Scholar was conducted through March 2026. Studies comparing MI (laparoscopic or robotic) with open PE for locally advanced colorectal cancer were included. The primary outcome was postoperative complications, and secondary outcomes were blood loss, operating time, hospital stay, 30-day mortality, readmission, and R0 resection. Random-effects meta-analyses were performed using risk ratios (RR) and weighted mean differences (WMD). RESULTS: A total of 14 observational studies, including 1,428 patients (610 MI, 818 open), were included. MI PE was associated with a significantly lower risk of total complications (RR 0.70, 95% CI 0.55-0.89, p=0.003) and wound infections (RR 0.40, 95% CI 0.23-0.69, p=0.0009). Major complications were comparable overall but lower with laparoscopic-only PE. MIS was associated with significantly lower blood loss (WMD -632mL, p<0.001) and shorter hospital stay (WMD -4.43 days, p=0.0006), with similar operating time. There were no differences in 30-day mortality or readmission. The R0 resection rates were similar (RR 1.03, p=0.191). CONCLUSIONS: MI PE is likely associated with favorable perioperative outcomes compared to open PE. Therefore, MIS may be used in select patients undergoing PE. However, our findings should be cautiously interpreted because the current evidence is mainly observational and remains prone to selection bias and residual confounding.