Abstract
Background/Aim: Pelvic exenteration (PE) remains one of the most radical procedures in gynaecological oncology and is associated with substantial morbidity and long-term complications. We aimed to synthesise evidence on short and long-term QoL outcomes following PE for advanced or recurrent gynaecological malignancies.
Methods: A systematic review was conducted using a prospectively registered protocol and reported in accordance with PRISMA guidelines. MEDLINE, Embase, PubMed and the Cochrane Library were searched from inception to October 2025. Eligible studies reported on one or more patient outcomes, including generic health QoL, sexual function, body image, menopausal symptoms and/or psychological distress. Risk of bias was assessed using ROBINS-I. Qualitative data synthesis was undertaken.
Results: A total of 23 studies comprising 1,655 patients were included, of whom 746 contributed QoL data. No randomised trials were identified. There were equal numbers of prospective and retrospective studies (11/23 each), and 17/23 studies carried a serious risk of bias. Global QoL trajectories were variable in the early postoperative period, with 2/9 studies reporting deterioration, 3/9 stability and 4/9 improvement within the first six months. Beyond six months, most studies (5/9) demonstrated stabilisation or recovery (3/9) of QoL. In contrast, domain-specific morbidity was common and persistent. Sexual function deteriorated in 11/14 studies, body image worsened in 8/12 studies (often associated with stoma formation) and psychological distress increased in all studies assessing this outcome. Dual stomas, infra/trans-levator resections and adjuvant radiotherapy were associated with poorer QoL, while vaginal reconstruction was associated with improved outcomes.
Conclusion: PE may permit acceptable long-term global QoL in selected women; however, this is frequently achieved at the cost of sustained sexual, body image and psychological morbidity. Multidimensional QoL assessment should be integral to patient selection, counselling and survivorship care. There is an imminent need for future prospective studies with standardised longitudinal QoL.
Introduction
Pelvic exenteration (PE) is a radical surgical procedure primarily aimed at recurrent or advanced gynaecological malignancies, including, but not limited to, cancers of the cervix, vagina and vulva (1). The nature of PE is further classified to anterior (APE), posterior (PPE) or total (TPE) depending on whether bladder and/or bowel are resected (1), commonly necessitating concurrent resection of levator ani muscle (infralevator/translevator PE) (2). Extended PE (EPE) and laterally extended endopelvic resection (LEER) represent modified versions of PE, involving en bloc resection beyond standard anatomical boundaries to achieve clear margins in cases with locally advanced or laterally invasive disease (3). Due to the extensive nature of the PE, urinary diversion via a urinary conduit and formation of an end colostomy are commonly necessary (2). While this surgery can be life-saving, its high-risk nature entails significant potential complications (4), particularly concerning postoperative morbidity and its impact on quality of life (QoL) (5).
With complication rates as high as 75% in gynaecological oncology patients (6), it is crucial to evaluate how PE affects patients’ QoL (5), the extent of which is yet to be clearly delineated in gynaecological oncology patients. Careful counselling with credible data is therefore essential to ascertain suitable surgical candidates and ensure that patients appreciate the vital changes in their post-operative QoL.
For selected patients, PE offers encouraging oncological outcomes, with reported 5-year survival rates reaching up to 60% (7). This has led to an increasing population of long-term survivors following the procedure (7). As survival rates improve, understanding and addressing the long-term impacts on QoL become more important. Consequently, a larger proportion of these survivors present to healthcare professionals with a range of physical and psychological challenges (8), which are often direct consequences of the morbidity associated with PE. Despite being critical, there is no robust short or long-term data on QoL post PE for gynaecological malignancies exclusively.
To address these gaps, we performed a systematic review to assess the impact of PE on QoL outcomes in women with advanced or recurrent gynaecological malignancies. This study aimed to evaluate generic health (global) QoL, sexual function, body image, menopause status and psychological distress, including anxiety and depression.
Methods
We conducted the systematic review following a prospectively registered protocol (PROSPERO CRD420251158130) and reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (9).
Literature search. We searched Embase, MEDLINE, PubMed and the Cochrane Library from inception to October 2025 for publications, using a predefined search strategy (Appendix 1). We conducted preliminary searches, and our final search strategy was validated by identifying a set of five eligible studies by our preliminary search (10-14). Reference lists from relevant studies and reviews were also searched manually to identify additional eligible publications.
Inclusion criteria. We followed a population, intervention, comparison, outcomes and study design (PICOS) (15) framework to specify our inclusion criteria. Population included women with advanced or recurrent gynaecological malignancies. Intervention was defined as any form of PE surgery. This included extended PE (EPE) and Laterally Extended Endopelvic Resection (LEER), which represent modified versions of PE, involving en bloc resection beyond standard anatomical boundaries to achieve clearance. Comparators included surgical extent and type of PE, vaginal reconstruction, ostomy formation, urinary diversion, adjuvant therapy, age, cancer type, and follow-up duration. Outcomes included generic health (global) QoL, sexual function, menopause status, body image and psychological distress, including anxiety and depression. We evaluated the study design, which consisted of randomised studies and non-randomised studies, prospective and retrospective cohort studies.
Exclusion criteria. We excluded case reports, review articles and studies which only involved Combined Operative and Radiotherapeutic Treatment (CORT) or studies which described PE interventions in women for other malignancies.
Selection process. Retrieved articles were transferred to EndNote 2025 (16) reference management software. References were then imported into Covidence 2025 (17), where duplicates were removed, and articles were screened. Two pairs of reviewers (N.A.S./H.L.R., N.A.S./M.E.L.) independently screened titles and abstracts. Full texts of the shortlisted abstracts were subsequently retrieved independently by N.A.S./H.L.R./M.E.L. to assess eligibility for inclusion for data extraction. Disagreements were resolved by the senior author (M.S.).
Quality assessment. Two pairs of reviewers (N.A.S./H.L.R., N.A.S./M.E.L.) independently assessed the quality of each study using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool (18). Disagreements were resolved by discussion with M.S. The following ROBINS-I domains were assessed: bias due to confounding, bias in the classification of interventions, bias in the selection of participants into the study, bias due to deviations from intended interventions, bias due to missing data, bias in the measurement of outcomes, and bias in the selection of the reported result. Each domain was rated as having low, moderate, serious, or critical risk of bias. An overall risk of bias judgement for each study (low, moderate, serious, or critical) was also assigned.
Data extraction. N.A.S., H.L.R. and M.E.L. independently extracted data using data extraction tables on Covidence (17), with inclusion determined by consensus. Disagreements were resolved by M.S. Data on study design, methods, population, interventions, QoL assessment tools and outcomes (QoL, sexual function, menopause status, body image and psychological distress, anxiety and depression) was extracted.
Data synthesis. For qualitative synthesis, we summarised and coded the key findings for each QoL domain, along with a conclusion on the impact of PE on patient-reported QoL outcomes. Since we anticipated a huge variation in outcome reporting along with different reporting tools, a meta-analysis was not intended as part of this review.
In accordance with the journal’s guidelines, we will provide our data for independent analysis by a selected team of the Editorial Team for the purposes of additional data analysis or for the reproducibility of this study in other centres if such were requested.
Results
The literature search retrieved 1566 studies. After 751 duplicates were removed, we screened 815 studies. Of these, 120 studies were assessed for eligibility and 23 met the inclusion criteria (Figure 1). Although these studies discussed N=1,655 patients, only N=746 women had assigned QoL data and/or met the criteria of our population. Mean age at the time of QoL assessment was reported in 14 studies (13, 14, 19-31), ranging from 41 to 60 years, while median age was reported in 9 studies (10-12, 32-35), ranging from 47 to 59 years.
PRISMA 2020 (40) flow diagram illustrating the identification, screening, eligibility assessment, and inclusion of studies in the systematic review.
Of 23 included studies, none were randomised control trials, 11 (14, 20, 21, 23, 27-30, 34-36) were retrospective cohort in design, 11 (10-13, 22, 24-26, 31-33) were prospective cohort studies, and 1 study (19) had both a prospective and retrospective cohort design. Ten studies (10, 19, 21, 22, 25-27, 30, 31, 34) originated from the United States, with the remaining 13 studies originating from Germany (11, 12, 23, 28, 33, 36), Italy (11, 24), France (13, 32, 35), India (29), Romania (14), and Czech Republic (20). Five studies (12, 21, 22, 31, 36) were published before the year 2000, and eighteen studies (10, 11, 13, 14, 19, 20, 23-30, 32-35) were published from the year 2000 onwards.
TPE was reported in 18 studies (10-14, 19-22, 24, 26, 27, 29-31, 33-35) (N=276 women). Of these, two studies (20, 33) reported extended TPE procedures (N=29 women). Eighteen studies (10-14, 20-22, 24, 26, 27, 29-35) reported APE (N=276 women). Of these, two studies (20, 33) reported extended APE procedures (N=16). A total of 13 studies (10-14, 20, 26, 27, 29, 30, 32, 33, 35) included PPE (N=149 women). Of these, two studies (20, 33) reported extended PPE procedures (N=5 women). Four articles (23, 25, 28, 36) did not specify the type of PE performed.
Seventeen studies (10, 11, 13, 19-22, 24-27, 30-35) included patients with mixed gynaecological pathologies. Cervical cancer was reported in 20 studies (10, 11, 13, 14, 19-27, 29-35) (N=498 women). Uterine malignancy was reported in six studies (10, 13, 30, 32-34) (N=58). Endometrial malignancy was reported in nine studies (11, 19, 20, 22, 24, 26, 27, 30, 35) (N=54). Vulvar malignancy was reported in nine studies (10, 11, 20, 22, 25, 26, 30, 33, 34) (N=52). Vaginal malignancies were recorded in eight studies (10, 11, 21, 22, 26, 27, 30, 33) (N=30). Ovarian malignancies were reported in six studies (10, 20, 24, 25, 27, 30) (N=10). ‘Other’ gynaecological malignancies were reported in seven studies (13, 19, 26, 30, 32-34) (N=16 patients). Five studies (13, 21, 27, 31, 32) reported mixed gynaecological malignancies (N=181). The type of gynaecological malignancy was unspecified in three studies (12, 28, 36) (N= 87). A summary of the study characteristics is presented in Table I.
Study characteristics of the 23 included studies.
Fourteen studies (11, 14, 19-22, 25, 26, 28-30, 33, 35, 36) did not report baseline generic health QoL scores. Of the nine studies (10, 12, 13, 23, 24, 27, 31, 32, 34) that reported baseline QoL, six (12, 13, 23, 31, 32, 34) reported a moderate QoL level at the preoperative baseline, two (10, 24) reported a low baseline QoL, and one (27) reported a high baseline QoL.
Eleven studies (11, 14, 19, 20, 22, 25, 26, 30, 31, 33, 35) used a one-off QoL assessment following PE. Twelve studies (10, 12, 13, 21, 23, 24, 27-29, 32, 34, 36) assessed QoL at multiple intervals. The timing of postoperative QoL assessments varied across studies and included assessments at seven days in one study (24), one month in three studies (13, 24, 32), two months in one study (29), three months in five studies (13, 24, 27, 32, 34), four months in five studies (12, 23, 28, 34, 36), six months in seven studies (10, 13, 24, 27, 29, 32, 34), 12 months in eleven studies (10, 12, 13, 23, 24, 27-29, 32, 34, 36), 24 months in one study (34), 35 months in one study (34), 36 months in one study (34), and 60 months in one study (34). One study (21) did not specify the timing of QoL assessments.
Of the 11 studies (11, 14, 19, 20, 22, 25, 26, 30, 31, 33, 35) that used a one-off QoL assessment, 10 (11, 14, 19, 20, 22, 26, 30, 31, 33, 35) reported the median duration of follow-up from PE to QoL assessment, with reported follow-up durations ranging from 12.5 months to six years. A summary of the assessment intervals is presented in Table I.
Thirteen studies (10-14, 20, 23, 24, 27-30, 32) utilised more than one generic health QoL assessment tool. Five studies (19, 21, 22, 25, 26) assessed generic health QoL using qualitative, unvalidated interview methods. The European Organisation for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) was used in 11/14 studies (11, 13, 14, 20, 24, 27, 29, 30, 32, 34, 35) as a quantitative QoL measure. Two studies (34, 35) used the EORTC QLQ-C30 as a standalone measure, while nine studies (11, 13, 14, 20, 24, 27, 29, 30, 32) used it alongside other QoL assessment instruments and disease-specific instruments. These disease-specific instruments included the EORTC ovarian cancer module (EORTC QLQ-OV28) used in two studies (13, 32), cervical cancer module (EORTC QLQ-CX24) used in three studies (11, 14, 20), colorectal cancer module (EORTC QLQ-CR38) used in one study (27), muscle-invasive bladder cancer module (EORTC QLQ-BLM30) used in one study (27), the sexual well-being module (EORTC QLQ-SWB3) used in one study (24), the Sexual Well-Being (SWB) scale used in one study (24), and the QOLPEX questionnaire used in one study (20).
Other generic health QoL instruments used included Short Form-12 (SF-12), used in one study (10) and the Functional Assessment of Cancer Therapy - General (FACT-G), used in one study (33). Cancer-related functioning and rehabilitation outcomes were assessed using the Cancer Rehabilitation Evaluation System (CARES) in two studies (12, 23). Stoma-specific QoL was measured using the Stomal QoL questionnaire and was used in two studies (10, 29).
Instruments assessing specific symptom domains were also used to assess secondary outcomes. Body image was evaluated using the Strauss and Appelt Body Image questionnaire, used in two studies (12, 23). Sexual function and sexual discomfort were assessed using the Sexual Activity Questionnaire (SAQ) used in one study (10), the Physical-Sexual Discomfort Scale, utilised in one study (28), and the Attractiveness/Self-Confidence Scale used in one study (28). Psychological outcomes were measured using the State-Trait Anxiety Inventory (STAI) for anxiety in one study (36), and the Center for Epidemiologic Studies Depression Scale (CES-D) for depressive symptoms in one study (30). Table II summarises the QoL instruments utilised.
Quality of life outcomes results reported of the 23 studies included. The table summarises quality of life assessment instruments, baseline quality of life where available, and reported changes in quality of life at ≤6 months and >6 months following pelvic exenteration, with interpretations of quality of life change.
Nine studies (10, 12, 13, 23, 24, 27, 29, 32, 34) reported changes in QoL within, or including, the first six months following PE. Of these, four studies (12, 13, 24, 32) reported an improvement in QoL during this period, one of which identified a statistically significant improvement (24). Three studies (23, 29, 34) reported no change in QoL within the first six months. Two studies (10, 27) reported a significant worsening in QoL during this early postoperative period.
Nine studies (10, 12, 13, 23, 24, 27, 29, 32, 34) reported QoL outcomes beyond six months following PE. Five studies (10, 12, 13, 32, 34) reported no change in QoL from six months onwards. Three studies (23, 24, 29) reported an improvement in QoL beyond six months, of which one study (24) found a statistically significant improvement. The remaining study (10) reported no change in stoma-related QoL, which remained at a moderate QoL level.
One study (20) assessed the difference between extended PE and PE postoperatively and found no significant difference between QoL outcomes post-PE between extended PE and non-extended PE. One study (30) assessed the effect of the type of PE on QoL and found no statistically significant difference in QoL based on the type of PE.
Fourteen studies (10, 12, 14, 19-23, 25-28, 31, 35) assessed sexual function following PE. Eleven studies (10, 12, 14, 21, 23, 25-28, 31, 35) reported a worsening in sexual function postoperatively, of which four (10, 27, 28, 31) demonstrated a statistically significant deterioration. In one study (27), sexual function worsened significantly at three months but subsequently returned to baseline levels. Three studies (19, 20, 22) did not report baseline sexual function values; of these, 2/3 (19, 22) reported low levels of sexual function postoperatively, while one (20) reported a moderate level of sexual function, with a significantly greater negative impact observed following PE compared with extended PE.
Four studies (13, 14, 20, 32) assessed menopausal symptoms following PE. Two studies (13, 32) reported an improvement in menopausal symptoms postoperatively. One study (14) reported a worsening, with increased menopausal symptoms after PE. The remaining study (20) did not report baseline menopausal symptom scores but found low levels of menopausal symptoms postoperatively, with no significant difference between PE and EPE groups.
Thirteen studies (10-14, 19, 20, 23, 26-28, 32, 35) assessed body image outcomes. Eight studies (10, 12, 14, 19, 23, 26-28) reported a worsening in body image following PE, of which five (10, 14, 19, 27, 28) identified a statistically significant deterioration. One study (27) reported a significant worsening in body image at three months, which subsequently returned to baseline levels. Three studies (13, 32) reported no change in body image from baseline. Two studies (11, 20, 35) did not report baseline body image scores but identified low levels of body image satisfaction postoperatively. One study (20) did not report baseline body image scores and found no significant difference in body image outcomes between PE and EPE groups. One study (19) reported that the observed deterioration in body image resulted from the presence of an ostomy.
Two studies (26, 31) assessed psychological distress following PE surgery. Both studies (26, 31) reported a worsening in psychological distress postoperatively. Two studies (31, 36) assessed anxiety outcomes. One study (36) reported an improvement in anxiety following PE, while the other (31) reported a worsening in anxiety postoperatively.
Five studies (10, 19, 21, 30, 31) assessed depression following PE. Three studies (21, 30, 31) reported worsening in depressive symptoms compared to baseline; from those, 1/5 (30) demonstrated a statistically significant increase in depression symptoms. One study (10) reported no significant change in depression levels from baseline. The remaining study (19) did not report baseline depression scores but identified high levels of depression postoperatively. Table III summarises the secondary outcomes.
Secondary quality-of-life outcomes after pelvic exenteration. Secondary outcomes assessed include sexual function, menopausal symptoms, body image, psychological distress, anxiety, and depression.
Two studies (11, 13) assessed the effect of the type of PE on body image. One study (11) found PPE/TPE had led to significantly worse body image post-PE compared to APE. The second study (13) found TPE led to worse body image, but this was not a statistically significant difference.
One study (14) compared QoL outcomes between supralevator and infralevator PE and found infralevator patients had significantly poorer QoL. Three studies (13, 23, 30) assessed the effect of age when undergoing PE on postoperative QoL. Of these, two studies (23, 30) found that age did not affect QoL post-PE. One study (13) showed that older age significantly worsened QoL, particularly in patients over 60. One study (11) assessed the effect of age on body image, which found older age to significantly worsen body image post PE.
Three studies (11, 12, 23) evaluated QoL outcomes in relation to the formation of an ostomy. All three studies (11, 12, 23) found that an increased number of ostomies led to significantly worsened QoL post-PE. Two of these studies (12, 23) found significantly worse QoL specifically in two ostomies compared with those with one or no ostomy. One study (11) found a higher number of ostomies and the formation of a permanent colostomy led to significantly worsened QoL.
Two studies (19, 28) assessed body image in relation to stomas. One study (28) found body image significantly worse with two stomas compared to one and no stoma. In the second study (19) a higher number of ostomies and the formation of a permanent colostomy led to significantly worsened body image after PE.
Five studies (11, 13, 30, 32, 34) assessed the impact of urinary diversion on QoL. Two (13, 32) of these studies found worse QoL in continent diversion compared to non-continent diversion at one month; however, this difference was no longer significant beyond the first postoperative month. Four studies (13, 30, 32, 34) found no significant difference between the type of urinary diversion one year post-operatively. One study (11) found that the formation of a non-continent bladder significantly increased the likelihood of worse QoL and body image post-PE.
One study (13) assessed QoL outcomes in relation to vaginal reconstruction, which found significantly improved QoL and psychological well-being in patients with vaginal reconstruction. One study (12) assessed body image in relation to vaginal reconstruction, which found that women with colpectomies without vaginal reconstruction had worse body image.
One study (23) reported sexual function outcomes in relation to neoadjuvant or adjuvant treatment. This study (23) found that women who had adjuvant radiotherapy had worse sexual QoL postoperatively compared to chemotherapy and chemoradiotherapy. The study (23) also identified that women with adjuvant therapy had worse body image scores post-PE than women without adjuvant therapy. One study (30) assessed QoL outcomes in relation to cancer type and found no statistically significant difference in QoL based on type of cancer. Seventeen studies (10-14, 20-22, 25, 26, 28-31, 33, 35, 36) had an overall serious risk of bias. Three studies (23, 27, 34) had a moderate risk of bias. Two studies (24, 32) had a low risk of bias. One study (19) had a critical risk of bias. Figure 2 summarises the quality assessment report.
Discussion
While PE remains among the most radical procedures in gynaecological oncology surgery, the present findings suggest that acceptable long-term global QoL can be achieved in certain patients, despite persistent sexual, body image, and psychological morbidity.
This systematic review indicates that PE surgery substantially and multidimensionally affects QoL in women treated for advanced or recurrent gynaecological malignancies in both short and long-term. PE was associated with variable early postoperative trajectories in generic QoL, but these were often recoverable, with the overall pattern indicating that acceptable long-term QoL is achievable in selected patients. Within the first six months following surgery, generic health QoL improved in just under half (44.4%) of the studies (12, 13, 24, 32), indicating that short-term recovery is feasible despite the radicality of the procedure. Beyond six months, most studies (10, 12, 13, 23, 24, 32, 34) described stabilisation or improvement in QoL, supporting the concept of postoperative adaptation over time.
Despite an overall trend toward recovery or stabilisation in generic QoL, a persistent burden was evident across several domain-specific secondary outcomes. Sexual dysfunction was the most consistently impaired domain, worsening in 11 of 14 studies (10, 12, 14, 21, 23, 25-28, 31, 35) and rarely returning to baseline levels. Body image also deteriorated in the majority of studies (10, 12, 14, 19, 23, 26-28) (8 of 13 studies), frequently in association with stoma formation, extensive perineal resection, and altered genital anatomy. Psychological distress emerged as a common concern, with all studies (26, 31) assessing psychological distress reporting postoperative worsening. Depressive symptoms worsened in most studies (21, 30, 31) (3/5 studies), although the available evidence was limited. Menopausal symptoms demonstrated variable patterns (13, 14, 20, 32) with no consistent direction of effect. Anxiety outcomes were inconsistent, showing both improved (36) and worsened (31) outcomes, preventing a clear conclusion regarding postoperative anxiety. This divergence between relatively stable global QoL scores and persistent domain-specific morbidity highlights a key limitation of relying solely on composite QoL measures to evaluate patient-centred outcomes following PE.
Several factors appear to influence QoL trajectories. All three studies (11, 12, 23) assessing stomas reported significantly worse QoL with increasing numbers of stomas, particularly in patients with two stomas (12, 23) or a permanent colostomy (11). Surgical approach also influenced outcomes, with infralevator procedures associated with significantly poorer QoL compared with supralevator approaches in the single study (14) evaluating this factor, likely reflecting greater anatomical and functional disruption. In contrast, the overall extent of resection, standard PE compared to extended PE, was not associated with differences in global QoL in the one study (20) assessing this comparison, and QoL did not differ significantly by PE subtype in one study (30). Urinary diversion type appeared to influence early postoperative QoL, with worse short-term outcomes reported for continent diversion compared with non-continent diversion in two studies (13, 32); however, these differences were not sustained, and long-term (one year post-PE) QoL did not differ by diversion type in four studies (13, 30, 32, 34). Reconstructive procedures, particularly vaginal reconstruction, were associated with improved QoL, psychological wellbeing, and body image in the limited available evidence (12, 13). Adjuvant radiotherapy was associated with poorer sexual function and body image in one study (23), while increasing age demonstrated inconsistent associations with QoL across three studies (13, 23, 30), suggesting that age alone may be less influential than baseline functional status, psychological resilience, and social support. These findings highlight the importance of patient-centred selection and counselling that integrate functional and psychosocial risks alongside surgical and oncological considerations.
Overall, these findings indicate that PE may allow long-term global QoL recovery in selected women, but commonly at the cost of sustained sexual, body image, and psychological morbidity. The quality and consistency of the evidence are limited, emphasising the need for cautious interpretation.
Results in the context of published literature. This is the first systematic review addressing QoL outcomes post PE surgery in the context of gynaecological malignancies. Previous studies have largely focused on oncosurgical outcomes and postoperative morbidity rather than QoL or have not examined gynaecological malignancies in isolation (8, 37). Harji et al. (8) assessed QoL following PE in a heterogeneous cohort that included rectal and other malignancies and primarily reported health-related QoL. In contrast, this present review focuses exclusively on gynaecological malignancies and evaluates generic QoL domains. By systematically reviewing the available evidence, this review clarifies patterns of global and domain-specific QoL outcomes while highlighting variability and limitations within the existing literature.
Strengths and weaknesses. This review represents the first comprehensive synthesis to date of QoL outcomes following PE surgery specifically in gynaecological malignancies. Key strengths include prospective protocol registration, adherence to PRISMA methodology, independent screening and data extraction, and structured risk-of-bias assessment using a validated tool. By distinguishing between short and long-term QoL trajectories and extending beyond generic QoL measures to examine domain-specific outcomes, including sexual function, body image, menopausal symptoms, and psychological distress, this review provides clinically meaningful insights to inform patient counselling and suggests design and direction of future research.
The strength of the conclusions drawn from this review is limited by substantial methodological weaknesses in the existing literature. Many studies were retrospective, with small sample sizes, serious risk of bias, inconsistent use of validated QoL instruments, and heterogeneity in assessment timing, all of which limit internal validity and generalisability. Wide variation in follow-up duration also increases susceptibility to recall bias, while the frequent absence of standardised baseline QoL assessments restricts interpretation of change over time. These limitations highlight the urgent need for prospective, methodologically robust QoL research for PE care pathways.
Implications for practice and future research. PE should be delivered within a structured multidisciplinary framework integrating oncological, surgical, psychological, and rehabilitative expertise. Given the predictable and sustained impact on sexual function, body image, and mental health, early and routine involvement of psycho-oncology services, sexual health specialists, and specialist stoma care teams is essential.
Preoperative counselling should be comprehensive, realistic, and individualised. Patients should be informed not only about survival and complication risks but also about anticipated long-term changes in sexuality, body-image perception, and psychological well-being. The use of decision aids, written survivorship information, and peer-support groups may facilitate shared decision-making and help minimise decisional regret. Framing PE as a survivorship-altering intervention rather than a purely curative procedure may support more informed and realistic expectations.
Patient selection should extend beyond oncological resectability alone. Women considering PE often face a binary choice between potentially curative surgery and palliative alternatives, highlighting the importance of holistic assessment. Preoperative evaluation of frailty, baseline QoL, psychological vulnerability, and social support should inform surgical candidacy and perioperative planning. Where modifiable risk factors are identified, such as untreated depression, anxiety, or inadequate stoma preparedness, targeted prehabilitation and psychological interventions should be implemented. Preoperative baseline performing status (PS) should also be considered. Several studies support elderly (38, 39) or women with poorer nutritional statuses (39) before PE experienced worse postoperative morbidity.
Postoperative follow-up should incorporate routine, longitudinal assessment of QoL using validated instruments. Reliance on global QoL scores alone is insufficient; domain-specific tools addressing sexual health, body image, and psychological distress should be embedded within standard care pathways. Early identification of deteriorating domains may enable timely intervention and optimise long-term outcomes, while future prospective studies should prioritise consistent baseline and longitudinal QoL assessment to strengthen the evidence base.
Conclusion
PE may permit acceptable long-term global QoL in selected women with advanced or recurrent gynaecological malignancies. However, this is frequently achieved at the cost of persistent sexual, body image, and psychological morbidity, which is not fully reflected in generic QoL measures alone. These findings emphasise the need to incorporate multidimensional QoL considerations into patient selection and counselling alongside oncological outcomes, with improved standardisation of QoL reporting. Given the heterogeneity and methodological limitations of the existing literature, prospective studies with standardised baseline, longitudinal and domain-specific QoL assessment are required to provide high-quality future research and better inform clinical decision-making.
Footnotes
Authors’ Contributions
N.A.S., M.S. - Conceptualization, methodology. N.A.S., H.L.R. and M.L. – Screening and data extraction. N.A.S. – Formal analysis. N.A.S., A.S, S.O., N.L., A.J., M.S. – Writing – original draft. N.A.S., A.S, S.O., N.L., A.J., M.S. Writing – review & editing. M.S., A.J., R.M., S.P., – Supervision. All Authors read and approved the final manuscript.
Conflicts of Interest
Ranjit Manchanda declares research funding from the Eve Appeal, NHS Innovation Accelerator, British Gynaecological Cancer Society, GSK, and Yorkshire Cancer Research outside this work and an honorarium for grant review from the Israel National Institute for Health Policy Research and an honorarium for advisory board membership from Astrazeneca/MSD/EGL/GSK. Ranjit Manchanda is the Topic Advisor for the NICE Guideline [GID-NG10225] – Ovarian cancer: identifying and managing familial and genetic risk. O.B. acknowledges support from Barts Charity (G-001522). The other Authors declare no conflicts of interest.
Artificial Intelligence (AI) Disclosure
No artificial intelligence (AI) tools, including large language models or machine learning software, were used in the preparation, analysis, or presentation of this manuscript.
- Received March 16, 2026.
- Revision received March 29, 2026.
- Accepted April 9, 2026.
- Copyright © 2026 The Author(s). Published by the International Institute of Anticancer Research.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
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