Pelvic exenteration (PE) is one of the radical surgical options for treating locally advanced or recurrent pelvic malignancies. However, due to its high degree of invasiveness, elevated complication rates, and significant perioperative mortality, clinical decision-making and patient selection present substantial challenges. Traditional studies have primarily focused on outcomes from the physician’s perspective, such as R0 resection rates and survival, while often overlooking patients’ long-term quality of life and decision-making experiences. In recent years, the concept of enhanced recovery after surgery (ERAS) has been gradually introduced into PE. Current evidence suggests that while the application of ERAS in PE is associated with reduced hospital stays and a lower incidence of severe complications, the simple adoption of standard colorectal or gynecological ERAS protocols in the PE population may lead to increased complications such as intestinal paralysis, urinary leakage, and pelvic abscesses. Metrics including patient-reported outcomes (PROMs) and quality of life (QoL), indicate that some patients, even after achieving R0 resection and long-term survival, still express hesitation or regret regarding their decision to undergo PE. This review, based on an analysis of the anatomical and demographic characteristics of PE as well as perioperative challenges, systematically summarizes the current status and main findings of ERAS application in PE, synthesizes evidence on long-term survival and quality of life following PE, highlights the discrepancies in outcome evaluation between physician-centered and patient-centered perspectives, and proposes a risk-stratified, PROMs-based PE-specific ERAS pathway alongside multidisciplinary, patient-centered management recommendations. The aim is to provide a reference framework for clinical practice and future research.