Historical Evolution of Pelvic Exenteration Surgery in Gynecologic Cancers: A Systematic Review and Meta-Analysis of Brunschwig's Era versus Contemporary Practice

Abstract

BACKGROUND: Pelvic exenteration (PE) is a radical surgical option for locally advanced or recurrent gynecologic cancers, but its contemporary risk-benefit profile has never been systematically compared with the original Brunschwig experience. The purpose of the study was to quantify changes in major postoperative morbidity, perioperative mortality, and oncologic outcomes after PE between Brunschwig-era series (1954-1969) and contemporary series (1990-2024). MATERIALS AND METHODS: This was an International Prospective Register of Systematic Reviews (PROSPERO)-registered (CRD420251009209) systematic review and meta-analysis. PubMed/MEDLINE, Web of Science, and Scopus were searched through December 2024 for studies reporting complications, mortality, or survival after pelvic exenteration for gynecologic malignancies. Two reviewers independently performed study selection and data extraction. Major morbidity was harmonized to Clavien-Dindo grade III or higher (or equivalent). Random-effects meta-analyses were performed where appropriate. All eligible studies identified were retrospective series. RESULTS: A total of 34 studies (5478 patients; 913 historical and 4565 contemporary) were included. Major morbidity decreased from 58% (95% CI 46-68%) in historical series to 23% (95% CI 17-31%) in contemporary series, while perioperative mortality declined from 23 (95% CI 17-30%) to 3% (95% CI 2-4%). Contemporary series also reported improved oncologic outcomes, although heterogeneity and differences in follow-up precluded direct survival comparisons. CONCLUSIONS: Compared with the original Brunschwig era, contemporary pelvic exenteration is associated with substantially lower major morbidity and perioperative mortality, together with improved oncologic outcomes. These findings illustrate the remarkable technical and conceptual evolution of pelvic exenteration over the past seven decades, although direct comparisons between historical and contemporary series should be interpreted cautiously because of differences in patient selection and clinical practice over time.