Clinical staging, bipedal lymphangiography, and extraperitoneal pelvic and paraaortic lymphadenectomy were performed in 95 patients with invasive squamous carcinoma of the cervix. Radiation therapy was modified on the basis of findings at operative staging. Patients have been followed from 16 to 91 months, with a mean of 41 months. The accuracy of clinical staging and the relative abilities of lymphangiography and lymphadenectomy to assess the retroperitoneal lymph nodes have been determined. Five-year survival with respect to stage of disease and status of the pelvic and paraaortic lymph nodes was calculated by the life-table method. Seventy-five percent of patients with no lymph node metastases are projected to be alive at 5 years without recurrence. Fifty-six percent with pelvic lymph node metastases and 23% of those with paraaortic lymph node involvement are projected to be free of disease at 5 years. The risk of lymph node metastases increases with either the stage of disease or the volume of the primary tumor independently of stage. The presence of lymph node metastases adversely affects survival regardless of the stage of the primary tumor. Clinical staging as accepted by FIGO is inadequate in that it ignores patients with pelvic or paraaortic lymph node metastases. The accuracy of detection in the individual patient does not increase with the addition of lymphangiography. Operative staging can be performed safely by the extraperitoneal route and radiation therapy can be modified on the basis of the true extent of disease. Radiation therapy fails to cure patients because of distant dissemination of disease as well as an inability of conventional radiotherapeutic techniques to sterilize a large primary tumor volume.