Total pelvic exenteration (TPE) has become an important modality for the treatment of locally advanced/recurrent rectal cancer. With the advancement of surgical techniques, the improvement of perioperative management, and the development of multidisciplinary treatment, the radicality and long-term survival of TPE were improved under the guidance of accurate anatomical levels, and the recurrence rate was decreased. The resection of the pelvis (especially the high sacrum) and the sciatic nerve further improved the R0 resection rate. Due to the removal of more pelvic organs and tissue, the incidence of empty-pelvic syndrome after TPE was high and difficult to manage, and the reconstruction of pelvic floor defect with biological patches or myocutaneous flaps might help to reduce postoperative complications. Urinary system reconstruction and vascular reconstruction were difficult for TPE, and it was particularly important to select the appropriate reconstruction method.