Navigating pelvic anatomy for exenteration: a clinical guide for radiologists

Pelvic exenteration (PE) is a complex, potentially curative option for locally advanced or recurrent pelvic malignancies in which achieving an R0 margin is paramount. This clinical review provides a pragmatic, anatomy-driven framework to optimize preoperative assessment and multidisciplinary planning. Using a compartment-based schema-central, anterior, posterior, and lateral-the article maps tumor spread to structures that determine technical feasibility and functional outcomes. For each compartment, surgical implications and reporting "pearls and pitfalls" are summarized to ensure radiological interpretation directly informs surgical decision-making. Special attention is given to differentiating tumor infiltration from post-treatment fibrosis, particularly following chemoradiotherapy, where diffusion-weighted magnetic resonance imaging plays an important role in the attempt to differentiate residual disease from fibrosis and defining safe resection planes. The review outlines assessment of critical anatomical structures or variants that have implications for surgical planning or functional consequences for patients. In addition, reconstructive options and their imaging appearances are briefly discussed to aid postoperative assessment. Through detailed anatomical analysis and structured, compartment-based reporting, radiologists can enhance multidisciplinary communication, refine patient selection, anticipate morbidity, and ultimately increase the likelihood of achieving complete resection in pelvic exenteration.