BACKGROUND: Total pelvic exenteration is a radical surgical procedure for advanced pelvic malignancies. Traditionally, an ileal conduit is created on the right abdominal wall for urinary diversion and an end-colostomy on the left abdominal wall for fecal diversion. However, this approach is associated with increased morbidity and a negative impact on quality of life (QoL). A unilateral double-barrel urocolostomy (DBUC) offers an alternative using the sigmoid colon for urinary drainage. This can potentially reduce complications, improve QoL, and preserve the right vertical rectus abdominis muscle (VRAM) flap for pelvic reconstruction. This study aimed to evaluate the impact of the DBUC on 90-day morbidity and QoL of patients undergoing pelvic exenteration for locally advanced colorectal and anal cancer. METHODS: Data were prospectively collected from all patients who underwent pelvic exenteration with DBUC reconstruction for colorectal and anal cancer at our tertiary care center between January 2020 and May 2023. RESULTS: This study enrolled 20 patients. Postoperative complications were observed in 19 patients, including seven major complications. Two complications were directly attributable to the DBUC. Patients reported favorable QoL outcomes in terms of global health, functional ability, and symptom management, with expected limitations in physical performance due to extensive abdominal surgery. At 1 year after surgery, all the patients preferred the DBUC over separate bilateral ostomies. CONCLUSION: The DBUC procedure has demonstrated safety and efficacy in terms of short-term morbidity and favorable patient-reported QoL, making it an attractive alternative to dual ostomies for patients undergoing pelvic exenteration, particularly when VRAM reconstruction is considered.