The aim of this systematic review is to assess the urological complications that occur following total pelvic exenteration and to understand if there are any contributory factors.

A systematic review was conducted in accordance with PRISMA guidelines. Articles were obtained via search on PubMed/MEDLINE using the search term “Pelvic Exenteration” for studies published between 1st January 1990 and 31st December 2021. Articles with more than 10 TPE patients and reporting specifically on urological complications were included in the study. Additionally, articles not in the English Language, editorials, letters and expert opinions were also excluded
Information that was gathered from the studies included: the number of patients, mean/median age, age range, type of cancer, primary or recurrent malignancy, urological complication rates, and incidence of specific urinary complications.
Following this, Risk of bias assessment was conducted using ROBINS-1 and Newcastle-Ottawa assessment tools. This along with rating of certainty of evidence, GRADE, was done independently by two reviewers

Out of the 1776 articles found by the search, 21 were included in the final study. This group of studies was made up of 6 prospective cohort studies, 14 retrospective cohort studies and 1 retrospective case series. From these, 11 clearly showed outcomes from patients presenting with Colorectal or gynaecological malignancies while 2 reported on both. Furthermore, 17 studies reported results for specific urinary diversions. 2 for continent diversions, 13 for incontinent diversions and 2 reported for both. Additionally, 17 studies reported radiation status of patients.
Assessment of the studies showed moderate/severe risk of bias along with a low certainty of evidence for all studies reported.
Overall, 1487 patients underwent total pelvic exenteration. Patient ages ranged from 15 to 92 Radiation status was reported for 1400 patients with the majority 1039 (74%) patients receiving Radiotherapy prior to their surgery. There were 745 urological complications (50.1%), with some patients having multiple complications. Clavien-Dindo scores were reported for 522 patients with 218 (41.8%) patients having a Clavien-Dindo score >III (including non-urological complications). The most common complications observed were UTI/Pyelonephritis (n=261, 22.9%), Anastomotic Leakage (n=116, 8.9%) and Uretero-enteric strictures (n=91, 8.1%). 
There is significant association between the use of a continent diversion and the development of Obstruction/strictures/stenosis (p=0.000), Stones (p=0.000) and UTI/pyelonephritis (p=0.021).
Furthermore, 13 studies reported re-operation rates. There was a 14.9% (164/1019) reoperation rate with the most common cause reported being urinary leakage from the anastomosis (14/152, 9.2%).

Complication rates for total pelvic exenteration remain high despite improvements to surgical practice. 
Due to surgical complexity, variations in patient anatomy and variation in cancer progression, the overall approach needs to be decided on a case-by-case basis. The use of incontinent conduits has become more prevalent over time with ileal conduits being the most used. Continent diversions were associated with higher rates of complications compared to incontinent, as per previous literature in cystectomy series for bladder cancer.
Studies assessing radiotherapy impact were mixed with some suggesting an increased risk and others not of developing complications. However, the majority of studies suggested patients were treated with pre-operative radiotherapy and so no firm conclusions could not be drawn.

The results revealed that complication rates for total pelvic exenteration remain high. The effects of other peri-operative factors such as chemo-radiation status and reconstruction type could not be fully established, due to the lack of information provided. Further well designed studies observing these are warranted.