Introduction: Pelvic exenteration (PE) is the only curative treatment for certain locally advanced intrapelvic malignancies. PE has high morbidity, and optimal reconstruction of the pelvic floor remains undetermined. Materials and methods: A retrospective chart review was performed at a tertiary university center to assess the surgical and oncological outcomes of 39 PE procedures over a 12-year period. The majority of patients (n ¼ 25) underwent transverse musculocutaneous gracilis (TMG) flap reconstruction for pelvic floor reconstruction. Results: The 1-and 5-year overall survival (OS) was 72% (95%CI 58%e86%) and 48% (95%CI 31%e65%), respectively. In multivariate analysis, lymph node metastasis (HR 3.070, p ¼ 0.024) and positive surgical margins (HR 3.928, p ¼ 0.009) were risk factors for OS. In this population, 71.8% of the patients had at least one complication. The complication rate was 65.4% and 84.6% for patients with versus without flap reconstruction, respectively (p ¼ 0.191). The length of stay was longer for patients with a major complication 16,0 ± 5,9 days vs. 29,4 ± 14,8 days, p ¼ 0,001, but complications did not affect OS. Conclusion: For selected patients, PE is a curative option for locally advanced, residual, or recurrent intrapelvic tumors. Pelvic floor and vulvovaginal defects can reliably be reconstructed using TMG flaps. TMG flaps are favored in our institution over abdominal-based flaps because the donor site morbidity is reasonable and TMG does not interfere with enterostomy.