R0 resection rates in minimally invasive versus open pelvic exenteration for colorectal malignancies: a systematic review and meta-analysis

Background and Objectives: Pelvic exenteration is a curative option for select patients with locally invasive or recurrent colorectal cancer. Achieving clear margins (R0 resection) is critical for optimal oncological outcomes and quality of life. Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, offers advantages in visualisation and precision, but its feasibility is debated given data limitations. This meta-analysis compares outcomes of MIS with open pelvic exenteration for colorectal cancer. Methods: A systematic review and meta-analysis were conducted with studies comparing MIS to open approaches for pelvic exenteration in colorectal cancer included. The primary outcome was R0 resection rate, with secondary outcomes encompassing operative, postoperative, and oncological results. Results: Seven retrospective studies were analysed, including a total of 564 patients. Meta-analysis showed no significant difference in R0 resection rates between MIS and open approaches (RR = 0.74, 95% CI: 0.36, 1.51, p = 0.41) with low heterogeneity (I² = 19%). MIS had similar lymph node harvest, operative time, and postoperative complications but demonstrated significantly reduced intraoperative blood loss, shorter length of stay, and improved 3-year overall and disease-free survival rates. Conclusions: MIS achieves comparable R0 resection rates to open surgery in pelvic exenteration for colorectal cancer, with advantages in recovery and survival outcomes. Current evidence is limited by retrospective studies with selection bias requiring future standardised prospective trials.