The status of the common iliac and aortic nodes is essential pretherapeutic

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1 1883 Extraperitoneal Endosurgical Aortic and Common Iliac Dissection in the Staging of Bulky or Advanced Cervical Carcinomas Denis Querleu, M.D. 1 Daniel Dargent, M.D. 2 Yann Ansquer 2 Eric Leblanc, M.D. 3 Fabrice Narducci, M.D. 1 1 Hopital Jeanne de Flandre, Division of Gynecologic Oncology, Lille, France. 2 Department of Obstetrics and Gynecology, Hopital Edouard Herriot, Lyon Cedex, France. 3 Centre Oscar Lambret, Lille, France. The authors thank Bruno Occelli, Dominique Lanvin, M.D., and Jean-Philippe Lucot, M.D. for their assistance in the clinical part of the study, and Bernard Castelain, M.D. for his invaluable collaboration as a radiation therapist. Address for reprints: Denis Querleu, M.D., Hopital Jeanne de Flandre, Lille Cedex, France. Received April 19, 1999; revision received August 16, 1999; accepted August 16, BACKGROUND. A pilot study of a new surgical technique for aortic dissection, combining the advantages of extraperitoneal surgery and minimal invasive surgery, was conducted. METHODS. Fifty-three patients underwent infrarenal aortic and common iliac dissection for the staging of bulky or advanced cervical carcinomas. The indication for extended lymph node staging was bulky early stage in 33 patients, International Federation of Gynecology and Obstetrics distal Stage IIB or higher in 14 patients, nonbulky early stage with microscopic positive pelvic lymph nodes in 1 patient, and central recurrence in 5 patients. The lymph node dissection template included the common iliac lymph nodes, the inframesenteric lymph nodes, and the preaortic and lateroaortic infrarenal lymph nodes. The operation was performed using endoscopic techniques with CO 2 insufflation of the extraperitoneal space. RESULTS. The procedure failed in two patients. Nine patients had lymph node biopsy or selective removal of macroscopically positive lymph nodes. For the 42 remaining patients, the average duration of the operation was minutes and the average number of lymph nodes was Overall, 17 patients had positive lymph nodes, in whom disease was macroscopic in 9 patients and microscopic in 8. Overall, the positivity rate was 32%. Five complications occurred, four of them related to the extraperitoneal dissection technique. An intraoperative complication occurred in one patient, in whom a lateral injury to a fixed and dilated ureter was managed by stenting. A postoperative complication occurred in another patient, in whom a retroperitoneal hematoma causing ileus and compression of the upper ureter was managed conservatively. Two symptomatic lymphocysts occurred; one of them required drainage under ultrasound guidance. All patients but one had external radiation therapy tailored according to the aortic lymph node status. After an average follow-up of 18.9 months, 60% of lymph node positive patients and 15% of lymph node negative patients died. Distant recurrence occurred in 53% of lymph node positive patients and 9% of lymph node negative patients. No patient had recurrence in the aortic or common iliac area. Two patients developed radiation enteritis. CONCLUSIONS. This new technique deserves to be used as a tool to identify lymph node positive patients who require extended-field radiation and/or chemotherapy. Cancer 2000;88: American Cancer Society. KEYWORDS: laparoscopic surgery, carcinoma of the cervix, aortic lymph node dissection, extraperitoneal surgery. The status of the common iliac and aortic nodes is essential pretherapeutic and prognostic information in advanced cervical carcinomas. 1 5 Imaging techniques are unable to reliably identify occult lymphatic spread. Investigation into the role of laparoscopic pelvic 2000 American Cancer Society

2 1884 CANCER April 15, 2000 / Volume 88 / Number 8 lymphadenectomy in the staging of early cervical carcinoma emerged in the late 1980s. 6,7 Considering the complication rate and cost of a laparotomy for aortic lymphadenectomy, 8 some investigators recently explored the feasibility of laparoscopic staging. 9,10 Evidence of a major reduction in adhesion formation rate after laparoscopic lymphadenectomy compared with transperitoneal laparotomy is available in experimental randomized studies. 11,12 It is generally accepted that the risk of radiation enteritis is reduced after extraperitoneal aortic dissection However, laparoscopic aortic dissection seems superior to extraperitoneal laparotomy as far as abdominal adhesion formation is concerned. 12 It thus was logical to investigate the combination of the endoscopic technique with the extraperitoneal approach. Vasilev and McGonigle 16 and Dargent 17 pioneered aortic dissection through an endoscopic extraperitoneal technique. Dargent 17 showed that the infrarenal aortic nodes can be reached through a leftsided approach. While starting in a clinical setting, we have chosen to complete our learning curve and to compare the two endoscopic approaches, respectively, laparoscopic and extraperitoneal, in a pig model. The results of this study give evidence that the extraperitoneal approach is as effective as the laparoscopic approach while inducing even less intraperitoneal adhesions. 18 Since then, over 100 patients have undergone extraperitoneal endoscopic dissection in our departments for gynecologic or urologic cancer. Fifty-three patients presenting with bulky or advanced cervical cancer are the subject of this study. METHODS Patients Fifty-three patients with pathologically proven cervical carcinomas gave informed consent for an extraperitoneal endoscopic common iliac and aortic dissection staging between Apri1, 1996 and September 1, The pathologic type was squamous in 44 patients and adenocarcinoma in 9 patients. The average age was 48.3 (standard error, 12.8; range, 27 78). The indication was bulky (International Federation of Gynecology and Obstetrics [FIGO] IB2 or Stages IIA to proximal IIB larger than 4 cm in diameter) early stage in 33 patients, FIGO stage greater than or equal to distal IIb in 14 patients, recurrence in 5 patients, and positive pelvic nodes in 1 patient. The latter patient presented with an early stage nonbulky tumor and negative frozen section examination of interiliac pelvic nodes; node metastasis was found at definitive pathologic examination. After exclusion of the patients presenting with recurrence, the FIGO stage of the 48 patients with primary tumor was IB1 (pn ) in 1 patient, IB2 in 18 patients, II (15 proximal, 2 distal) in 17 patients, III in 8 patients, and IVA in 4 patients. The procedure failed in two patients. One did not tolerate the extraperitoneal CO 2 insufflation, another had a laceration of the posterior parietal peritoneum, and both had to be converted to a transperitoneal approach, both having macroscopically involved nodes. Significant pathologic information concerning the lymph node status thus was obtained by extraperitoneal dissection in 51 patients (feasibility rate 96 %). In three patients, the operation was aborted because macroscopically involved lymph nodes were found; in all three cases, pathology was documented by means of removal of at least one diseased node and the remaining nodes were clipped for radiologic localization later. In another group of six patients, macroscopically positive nodes were selectively removed. The remaining 42 patients underwent a common iliac and inframesenteric aortic dissection completed by a dissection of the infrarenal preaortic and left aortic lymph nodes. The rationale for aortic/common iliac dissection was to tailor the extent of external radiation therapy. In our management protocol, common iliac node metastasis is managed in the same way as aortic node metastasis. One patient with recurrent disease and negative aortic nodes was eligible for exenteration. The remaining 35 lymph node negative patients were proposed pelvic radiation therapy. Twenty-nine of them had pelvic field radiation therapy (45 Grays external followed by 15 Grays brachytherapy) only. Another five patients presenting with IB2 tumor with negative aortic nodes had external pelvic radiation therapy and then underwent abdominal radical hysterectomy indicated for unsatisfactory response (less than 50% in tumor diameter) to external radiation therapy. One IB2 stage lymph node negative patient refused radiation therapy and was proposed abdominal radical hysterectomy. One positive lymph node patient underwent a pelvic debulking procedure before radiation therapy. The remaining 16 aortic/common iliac lymph node positive patients were given extended-field radiation therapy and brachytherapy, combined with chemotherapy in two patients, and did not undergo further surgical procedure. Operative Technique The patient lays flat on the operating table. The senior surgeon stands on the left side of the patient, the assistant standing on his left side. Both watch the monitor screen placed on the right side of the patient. The operation starts as a standard laparoscopy. After

3 Extraperitoneal Endoscopic Aortic Dissection/Querleu et al FIGURE 1. Extraperitoneal endoscopic view of the left psoas muscle (1), the common iliac artery (2), the ureter (3), and the ovarian vein (4) after finger preparation of the extraperitoneal space is shown. the pneumoperitoneum has been created, a 10-mm endoscope is placed at the inferior margin of the umbilicus. An additional 5-mm trocar is placed in the right lower quadrant to accommodate a palpator or a needle for sampling of the peritoneal fluid or a biopsy forceps in case of suspected peritoneal involvement. Additional information concerning the adnexa is obtained. A 15-mm incision is made 3 4 cm medial to the left iliac spine. The skin, fascia, transverse muscles, and deep fascia are incised, taking care not to open the peritoneum, which can be avoided if the laparoscopic view is used to check the undersurface of the abdominal wall of the left lower quadrant. The surgeon s left forefinger is introduced in the incision and frees the peritoneal sac from the deep surface of the muscles of the abdominal wall under laparoscopic monitoring. The dissection is easy in the iliac fossa, and the finger soon reaches the psoas muscle, then, more medially, the left common iliac artery. Both landmarks are easily identified with the fingertip as a result of shape (psoas muscle) or beating (common iliac artery). Both landmarks can be safely freed from the peritoneal sac as much as possible: the wider the finger preparation is, the shorter the endoscopic dissection will be. The separation of the peritoneum is more difficult in the cephalic direction, with a thinner and more attached peritoneal sac. It is, however, possible to separate a surface of the abdominal wall large enough to allow the introduction of two trocars, generally a 10-mm trocar higher and posterior to the first incision (on the middle axillary line), then a 5-mm trocar on the anterior axillary line approximately 5 cm below the ribs. Finally, the 15-mm incision is used to place a balloon trocar designed for open laparoscopy (Blunt-Tip ; Origin, Menlo Park, CA). The balloon is placed in the extraperitoneal space under laparoscopic guidance, inflated with saline and secured to the abdominal wall to ensure pneumostasis. The corresponding trocar is used to accommodate the endoscope. The peritoneal cavity is deflated while the extraperitoneal space is inflated with CO 2 up to a maximum pressure of 10 mm of mercury. The endoscopic view of the part of the extraperitoneal space prepared with the finger is clear from the very beginning of the introduction of the endoscope (Fig. 1). The left psoas muscle, the left ureter, and the left common iliac artery are identified before any endoscopic dissection. The instrumental trocars accommodate grasping forceps, monopolar scissors, and, when required, bipolar cautery. Endoscopic clips must be available to control bleeding from large vessels or to radiologically localize fixed lymph nodes. The endoscopic blunt dissection is guided by three major landmarks: the psoas muscle, the ureter, and the common iliac artery. The psoas muscle is freed up to the fascia of the kidney, which can be entered using scissors if the space is too narrow. The ureter is separated from the common iliac artery and lifted along with the peritoneal sac. Actually, only the

4 1886 CANCER April 15, 2000 / Volume 88 / Number 8 FIGURE 2. Final view of the dissection in the aortic area is shown. The aorta (1), the common iliac arteries (2 and 3), and the inferior mesenteric artery (4) are dissected. A left lumbar artery (5) also can be seen. lumbar and iliac segments of the ureter can be elevated, as the pelvic ureter and the upper lumbar ureter stay at the bottom of the dissection. As a result, the ureter forms a bow above the operative field throughout the dissection. The lateral aspect of the common iliac artery is used as a guide to dissect caudally down to the level of its bifurcation and up to the aortic bifurcation, then to the renal vessels. The surgeon then frees the anterior aspect of the common iliac artery vessels, knowing that the peritoneal sac and the ureter are attached to the iliac artery by small vessels that must be controlled before section. The surgeon frees the anterior aspect of the inframesenteric aorta, taking care not to injure the inferior mesenteric artery (Fig. 2). After these steps are achieved, the lateroaortic nodes and the lateral common iliac nodes can be easily detached from the large vessels, the lumbar vessels, the prevertebral fascia, and the sympathic nerves. The next step consists in reaching the right common iliac area. The peritoneal sac is elevated from the left common iliac vein, then from the sacral promontory. The bifurcation of the inferior vena cava is identified. Care must be taken not to injure the middle sacral vessels. The right common iliac vein then the right common iliac artery are freed by using blunt dissection. Further enlargement of the surgical space in this area requires pushing caudally, i.e., to the left side of the screen, the sigmoid colon, which is attached to the inferior mesenteric artery. Once identified, the right common iliac artery is followed in a caudal direction down to the level of its bifurcation. The crossing of the right ureter with the iliac vessels is reached. The right ureter then is elevated and separated from the iliac vessels and from the psoas muscle. The right ovarian vein is identified at the undersurface of the mesocolon. The presacral nodes and the right lateral common iliac nodes are ready for removal (Fig. 3). The precaval lymph nodes then are identifed and detached from the inferior vena cava. They usually stay attached to the vena cava by small vessels. They must be gently grasped and slightly elevated to identify, to control, then to cut these small vessels generally by using monopolar cautery. The inframesenteric preaortic lymph nodes are generally attached to the peritoneal sac and are easy to dissect. The laterocaval nodes can be dissected using the same dissection plane or alternately may be reached after division of two or three sets of lumbar vessels and elevation of the aorta and vena cava from the prevertebral fascia. The standard common iliac and inframesenteric dissection is completed. The infrarenal dissection (Fig. 4) requires great care and knowledge of the normal anatomy and of anatomic variants. It starts at the lateral aspect of the aorta. The lateroaortic lymph nodes located below the left renal vessels are dissected first. The lateroaortic part of the left renal vein is reached using blunt dissection. The venous network, including the lomboazygos vein and the end of the left ovarian vein, is carefully dissected. Generally, the dissection ends with the removal of the high preaortic and left lateroaortic lymph nodes. The dissection of the anterior aspect of the aorta and of the preaortic segment of the left renal

5 Extraperitoneal Endoscopic Aortic Dissection/Querleu et al FIGURE 3. Final view of the dissection in the common iliac area is shown. In addition to the two common iliac arteries (1 and 2), the left common iliac vein (3), the promontory (4), and the right ureter (5) are visible. A left lumbar vein (6) and the left sacrolumbar vein (7) also can be seen. FIGURE 4. Final view of the dissection in the infrarenal area is shown. The aorta (1) and inferior mesenteric artery (2), two lumbar arteries (3 and 4), the left renal vein (5), the lombo-azygos vein (6), a left polar artery (7), and corresponding vein (8) have been dissected. The sympathic nerve chain (9) is also an important landmark. vein requires the division of the left ovarian artery, which was not routinely performed in this series. In the same way, the separation of the aorta from the prevertebral fascia and the removal of the retrovascular (retrocaval and retroaortic) lymph nodes is feasible but not included in the standard dissection in cervical carcinomas. The procedure ends after a careful check of the hemostasis and cleaning of the operative field by using irrigation and suction. The extraperitoneal space is deflated. The 15-mm fascial incision is closed using 00 absorbable suture. No drainage has been used in this series. Since the occurrence of a bowel obstruction due to an incisional hernia through the umbilicus, we

6 1888 CANCER April 15, 2000 / Volume 88 / Number 8 TABLE 1 Lymph Node Positivity Rate According to Tumor Stage Stage n Patients with positive aortic nodes (%) IB1 pn Ib (22.2) 2 IIA/proximal IIB 15 4 (26.7) 2 Distal IIb 14 7 (50.0) 4 Recurrence 5 2 (40.0) 2 Total (32.1) 9 Patients with macroscopic positive nodes routinely close the 10-mm umbilical fascial incision. The other incisions are superficially closed using skin sutures or staples. RESULTS The average duration of the full procedure in 42 patients, excluding the 2 patients for whom the procedure was aborted and the patients who underwent biopsy or selective lymphadenectomy only, was minutes (standard deviation, 31.8; range, ). The average number of lymph nodes in the same 42 patients was 20.7 (standard deviation, 9.9; range, 10 44). Overall, 17 out of 53 patients (32%) had positive lymph nodes. As expected, the positivity rate was higher in the more advanced stages (Table 1). An intraoperative complication occurred in one patient. The left ureter was dilated as a consequence of stricture due to tumor extension in the pelvic area; the wall of the ureter was extremely thin and attached to a diseased common iliac lymph node. A lateral injury occurred as a result of blunt dissection. A percutaneous nephrostomy was placed and then removed after decompression of the ureter as a result of radiation therapy and spontaneous healing of the lateral defect. In two patients, the surgeon mentioned difficulty due to a ureterohydronephrosis in one patient and to a low position of the left renal vein in another patient. The patients were routinely discharged the following day or after 2 days. Three patients were readmitted because of complication. One patient experienced ileus due to a retroperitoneal hematoma, which also created a hydronephrosis. The patient was managed conservatively, with simple observation and placement of a double-j ureteral stent. An additional patient was readmitted and reoperated on the fifth postoperative day for bowel obstruction. The bowel obstruction was not related to the extraperitoneal dissection but was secondary to an umbilical incisional hernia. One symptomatic lymphocyst required surgical drainage, and one was managed during subsequent laparotomy for radical hysterectomy after completion of radiation therapy. Grade 3 radiation enteritis occurred in two patients after extended-field radiation therapy. One patient was the one who suffered from bowel obstruction. She had positive aortic lymph nodes and received extended-field irradiation. She later died from pulmonary metastasis. Another patient had to be operated for small bowel radiation enteritis; she is still living. The patient outcome was updated on March 20, Follow-up was obtained for 48 patients (average 18.9 months, range, 8 47). In the node positive group (n 15), 9 patients (60%) died, while in the node negative group (n 33), 5 patients (15%) died (p.01). Distant metastatis occurred mostly in aortic lymph node positive patients: 8 of the 15 (53%) lymph node positive patients and 3 of the 33 (9%) lymph node negative patients developed distant metastasis (p.01). DISCUSSION Less than 5% of patients presenting with nonbulky early cervical carcinoma have positive aortic nodes, and less than 1% have skip metastasis to the common iliac or aortic nodes. 19,20 In contrast, 11% patients with bulky tumors, 16% of advanced (IIB or more), and 25% of patients with positive pelvic lymph nodes have aortic metastasis. 8,9,20 These figures are a clear indication for routine node dissection. As imaging studies unfortunately do not provide sufficient information, surgical staging may be used to tailor therapy according to the lymph node status. At the beginning of our study, the upper limit of the aortic dissection was the inferior mesenteric artery. In an early series of eight patients operated on before the beginning of this prospective study, not included in this series, one patient recurred in the left infrarenal aortic area less than 1 year after a negative inframesenteric dissection. In addition, Michel et al. 20 found that the left paraaortic supramesenteric area can be involved alone. We thus have decided to extend the dissection up to the level of the renal vein. However, considering the finding that only the left upper aortic lymph nodes were found to be involved in the Michel s series, and considering the additional operating time and risks for the dissection of the upper right lymph nodes (precaval and laterocaval), we have limited the supramesenteric dissection to the preaortic and left paraaortic lymph nodes. The average number of 20 lymph nodes that we retrieve from the area thus defined is consistent with the number retrieved through an abdominal incision by surgeons dedicated to systematic lymph node dis-

7 Extraperitoneal Endoscopic Aortic Dissection/Querleu et al section. Benedetti-Panici et al. retrieved after a maximum surgical effort at open surgery a median of 20 nodes (range, 14 41) in endometrial and cervical carcinomas, 21 whereas Ballon et al. retrieved an average of 9.8 lymph nodes by an extraperitoneal open approach. 22 In addition, the observed proportion of patients with diseased nodes in this series of advanced cervical carcinoma is consistent with the expected positivity rate observed in the literature. 8,14,15,19 Finally, the aortic dissection was deemed unsatisfactory by the surgeon in only four patients of this series. In two patients, the procedure could not be completed. In one patient, it was not possible to dissect above an unusually low left renal vein, but the rest of the operation was performed satisfactorily, and 17 lymph nodes were removed. In the other patient, the view was obstructed by a ureterohydronephrosis, but 12 nodes were removed. The two latter patients were lymph node negative, had pelvic radiation only, and are free of disease until now. Thus, we feel that the prognostic information obtained with an extraperitoneal endoscopic dissection matches the information obtained at open surgery. The initial laparoscopic examination is not absolutely necessary from a technical point of view. The finger preparation of the extraperitoneal space and the placement of extraperitoneal trocars may be accomplished, in our study of male patients with testicular carcinoma, without laparoscopic monitoring and without the use of an expensive dilating balloon. 16 The rationale of laparoscopic examination in female patients presenting with cervical carcinoma is the assessment of peritoneal cavity, searching for spread to the ovary, bowel, omentum, and pelvic peritoneum. Intraabdominal spread to organs other than lymph nodes is noted in approximately 10% of patients. 8 However, the modern imaging technique, including magnetic resonance imaging, may detect the involvement of the outer surface of the cervix, thus reducing the need for laparoscopic examination and reducing the risk of complication resulting from the laparoscopic approach. It is also very likely that endosurgical aortic staging involves less cost and less surgical trauma than laparotomy. For example, 4 out of 120 patients died after the open surgery staging operation in an early series from the M.D. Anderson Cancer Center. Conversely, no patient from large series died after extraperitoneal open lymph node dissection. 13,14,22,23 The complication rate observed in this series is not superior to the complication rate observed after open surgery: 3 patients out of 20 in Gallup et al. s series suffered from complication. 23 However, lymph node count is not always available in the articles we surveyed, in which aortic lymph node dissection is described as selective, which probably means that dissection were less thorough and less extended than in our technique: the average lymph node count furnished by Gallup et al. 23 was only 9.8. In addition, wound infection that delays the initiation of radiation therapy is not uncommon after extraperitoneal laparotomy, 22 whereas the patients often are ready to begin radiation therapy within 7 10 days of laparoscopic surgery. Finally, the blood loss is insignificant in our series, in contrast with clinical study with aortic lymph node dissection. The radiation-induced complication rate is much lower after open extraperitoneal staging by open laparotomy compared with open transperitoneal laparotomy. Sixteen iatrogenic fatalities occurred in an early series of 120 patients after open transperitoneal staging. 8 A significant severe complication or fatality rate is still found in more recent series in spite of the reduction of dosage and use of modern radiation therapy techniques. 15 However, the rate of radiation-induced complications requiring surgery or causing death is only 9% in a series of patients surgically staged through a retroperitoneal approach, compared with 47% in a series of patients surgically staged through a transperitoneal approach, 15 which is in accordance with the findings of a Gynecologic Oncology Group study. 14 The retroperitoneal approach is a significant factor of reduction in complication and of improvement in survival in a multivariate analysis. 15 It can be assumed that the same is true for endoscopic techniques, knowing that the adhesion formation rate is lower after extraperitoneal endosurgical dissection compared with transperitoneal laparoscopic dissection in an animal model. 18 It is not clear whether consequent complications of radiation therapy are actually reduced after extraperitoneal endosurgery compared with open extraperitoneal surgery. Two cases of nonlethal Grade 3 radiation enteritis were noted in 17 patients who underwent extended-field radiation therapy in our series. Conversely, it seems that the radiation therapy complication rate is lower after laparoscopic pelvic lymphadenectomy compared with open staging. In a case control study of two groups of 26 patients with cervical carcinoma and positive pelvic lymph nodes, we found a significantly lower Grade 3 4 radiation therapy complication rate in the group of patients staged laparoscopically and who underwent radiation therapy only compared with patients managed by open radical surgery. 24 More patients and longer follow-up are necessary to estimate the radiation therapy complication rate and then to compare it with the expected rate of

8 1890 CANCER April 15, 2000 / Volume 88 / Number 8 complications observed after open extraperitoneal staging followed by extended-field radiation or observed after extended-field radiation without surgical staging. The complication rate of this purely diagnostic operation must be addressed and put into perspective with the complication rate of systematic extendedfield radiation therapy, which is estimated to be in the range of 10 14%. 25 More precisely, the key issue is the additional complication rate of an extended field compared with a pelvic field, which is estimated to be in the range of 4% in randomized studies. 26,27 In this series, two symptomatic lymphoceles and one ureteric injury were observed, for a complication rate of 5.7% (3 of 53), which is not different from the complication rate observed in series of open extraperitoneal lymph node dissection. 23 If the additional case of incidental laparotomy is taken into account, the estimate of complication rate is 7.6% (4 of 53). Only the latter complication required laparotomy and led to severe long term side effects, for a Grade 3 complication rate of 3%. This complication should no longer occur because we now suture the fascia of the umbilical incision, and the Grade 3 complication rate would have been 0 if we had taken this precaution from the beginning of our study. The severe complication rate of extraperitoneal endoscopic staging thus may prove to be extremely low and to compare favorably with the additional complication rate related to extended-field radiation therapy administered to all patients regardless their lymph node status. In addition, a systematic dissection of the common iliac area may result in a reduction of the radiation field in lymph node negative patients. The standard upper limit of the pelvic field is usually the junction of L4 and L5. 25 In our center, in the future, we will adapt the upper limit of the pelvic field to the radiologic localization of clips placed during endosurgery at the lower limit of the dissection, which is constantly below the level of the sacral promontory. Availability of surgically based information concerning the status of aortic lymph nodes may modify in the future the management of advanced cervical carcinomas, in addition to tailoring radiation therapy. The rational use of prescalenic biopsy in aortic lymph node positive patients may select those patients with high risk of early recurrence in distant sites, in whom locoregional radiation therapy may be insufficient, and in whom surgery is unnecessary. The indication for debulking of large diseased aortic lymph nodes, which is being proposed by some investigators, 28 is not established. If this procedure proves to be efficient in the future, patients may be selected thanks to endoscopic visualization, and the debulking operation can be performed during the same operating session through an extraperitoneal laparotomy. Finally, patients with positive aortic lymph nodes are at extremely high risk of developing distant metastases and may benefit from adjuvant systemic therapy. As a matter of fact, any trial addressing the issue of adjuvant chemotherapy in advanced cervical carcinoma should be based on adequately staged patients. The issue of the indication for aortic staging in advanced cervical carcinoma is still being debated. Theoretically, 6 out of 100 patients presenting with Stage II or Stage III could be salvaged by detection and treatment of positive aortic lymph nodes. 29 This figure is not a definitive argument against staging but makes the indication of open dissection, with inherent complication rate, controversial. If the results of this study are confirmed by further study, endosurgical common iliac and aortic dissection may become a mainstay of staging of advanced cervical carcinomas. While inducing a minimum of surgical trauma, it may spare the majority of patients who have no diseased lymph nodes the cost, side effects, and complications of an unnecessary extension of external radiation field. Conversely, patients with microscopically positive lymph nodes may benefit from adjuvant chemotherapy or extended radiation therapy. In this regard, only adequately staged patients are eligible to randomized trials. Finally, patients with macroscopically diseased lymph nodes undetected by imaging techniques may benefit from surgical debulking. New techniques such as extraperitoneal endosurgical aortic dissection may in the future modify the risk/benefit trade-off of surgical staging of advanced or bulky cervical carcinomas. REFERENCES 1. Nelson JH, Boyce J, Macasaset M, Lu T, Bohorquez JF, Nicastri AD, et al. Incidence, significance, and follow-up of para-aortic lymph node metastasis in late invasive carcinoma of the cervix. Am J Obstet Gynecol 1977;128: Hugues RP, Brewington KC, Hanjani P, Photopulos G, Dick C, Votava C, et al. Extended field irradiation for cervical cancer based on surgical staging. Gynecol Oncol 1980;9: Averette H, Donato D, Lovecchio J, Sevin B. 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