Post-chemoradiation T4 rectal cancer remains a therapeutic challenge and an aggressive surgical approach is the only chance for a cure. Rectal lesions infiltrating the upper vaginal wall and uterine cervix are usually treated by low anterior resection with en bloc removal of the vagina and uterus. However, failure can occur when one is trying to access the anterior recto-vaginal plane below the tumor, especially in obese patients with a narrow pelvis. The remaining surgical alternatives are aggressive and debilitating. The objective of the study is to describe a modified supralevator pelvic exenteration for selected patients. A new surgical option is added to the armamentarium of the oncologic surgeon. The discussion focuses on the indications for this surgical technique and its advantages, such as the preservation of the anal sphincter and the vagina, thus allowing for fecal continence and sexual activity.