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The development of compartmentalization of the pelvis and of partial exenteration resulted in more targeted approaches Bone resection was necessary for tumors involving the sacrum, coccyx, ischium, pubic symphysis, and/or ischiopubic rami [2]. Recent collaborative data show that bone resection (where needed) along with R0 margins are the most important factors influencing overall survival following PE for LRRC [5]. Disease proximal to the S1/S2 level was considered unresectable in many centers, and this represents another challenge [43–46].

Brunschwig and Barber reported a series of 28 patients, perioperative mortality was 29%, with five‐year survival of 15% [47]. These initial outcomes discouraged many from pursing en‐bloc bone resection. Research and better operative techniques developed for the management of sacral chordomas rekindled interest in composite PE in the 1980s [48]. Wanebo and Marcove (Charlottesville, USA) described the abdominal‐trans‐sacral approach for resecting LARC with sacral extension in 1981 (Figure 1.4) [49]. The initial dissection of the intrapelvic organs was accomplished through the traditional anterior approach followed by resection of the sacrum with the patient repositioned lying prone [46, 49]. Takagi and colleagues (Nagoya, Japan) encountered no postoperative mortality with this technique [50].

These outcomes stimulated research into the role of composite sacral resection for LARC and led to various units undertaking more radical resections, reporting morbidity rates between 40 and 91%, with < 5% perioperative mortality and five‐year survival of almost 50% [51–55]. In recent years, specialist units developed techniques for en‐bloc partial sacral resection. Hemisacrectomy, a procedure involving resection of the anterior cortex of the sacrum to preserve the sacral nerve roots, and segmental sacrectomy are alternatives [55–59].