Extended and Repeated Cytoreductive Surgery in Recurrent Uterine Leiomyosarcoma: A Narrative Review

Background/Objectives: Recurrent uterine leiomyosarcoma (ULMS) frequently poses a surgical question because systemic options remain limited and recurrence patterns are heterogeneous. We reviewed the published evidence on repeated and extended cytoreductive surgery for recurrent ULMS, focusing on selection criteria, operative boundaries, and the role of multivisceral, thoracic, and peritoneal-directed procedures. Methods: This narrative review synthesizes peer-reviewed literature on surgically managed recurrent or metastatic ULMS, prioritizing contemporary guidelines, retrospective cohorts, pooled analyses, selected systematic reviews when directly relevant to the surgical question, and published illustrative reports. The search covered records available from database inception through 14 May 2026 and used PubMed/MEDLINE, Web of Science Core Collection, Scopus, Google Scholar, selected publisher databases, and citation-linked records. No new patient-level or institution-specific clinical data are presented. Results: The available evidence is entirely retrospective and strongly affected by selection bias, yet it consistently suggests that the best outcomes are observed when complete gross resection is feasible. Across published series, favorable features include isolated or limited recurrence, longer time to relapse, compartmentalized disease, lung-only metastases, and preserved performance status. Contemporary reports also show that repeat surgery may evolve into extensive multivisceral procedures involving bowel resection, upper-abdominal dissection, urinary tract reconstruction, diaphragmatic resection, and thoracic surgery. Peritoneal-directed CRS/HIPEC-type strategies remain supported mainly by small heterogeneous studies and a ULMS-specific systematic review, reinforcing feasibility but not routine use. Published illustrative reports confirm that serial metastasectomies can occasionally support prolonged survival in exceptional patients, but they cannot establish effectiveness. Conclusions: In highly selected patients, repeated and even extensive cytoreductive surgery may remain a rational disease-control strategy for recurrent ULMS. The central unmet need is not proof that surgery can work in exceptional cases, but better criteria to identify who benefits from iterative resection and when escalation to multivisceral or thoracoabdominal surgery is justified.