Indian J Gynecol Oncolog (2015) 13:24 DOI 10.1007/s40944-015-0028-y
ORIGINAL PAPER
Peritoneal Carcinomatosis Index in Advanced Ovarian Malignancy either by Multislice CT verus Laparotomy: A Comparative Study Mahmoud Hanafy Meleis1 • Ahmed Mohammed Samy El-Agwany1
Received: 30 September 2015 / Revised: 11 November 2015 / Accepted: 13 November 2015 / Published online: 8 December 2015 Association of Gynecologic Oncologists of India 2015
Abstract Background Ovarian cancer is the fifth most common malignancy in women in developed world. It is the most common gynecologic malignancy to cause death in women worldwide. It usually affects women over the age of 60 years. Owing to the lack of early, effective screening tools and lack of specific symptoms associated with early stage disease, approximately 70 % of ovarian cancer patient are diagnosed at advanced stage. The peritoneal cancer index (PCI) is the method of measuring the amount and distribution of metastatic tumor in the peritoneal cavity on CT scan and laparotomy. It is based on tumor extent in 13 separate regions. Distribution of the implants on abdominal and pelvic surfaces greatly influences the likelihood of a complete cytoreduction by visceral resections. The Aim of the Study The aim of this study was to compare CT scan to laparotomy in calculation of PCI in cases of advanced ovarian cancer, to assess accuracy of CT scan in staging of ovarian cancer and to estimate the accuracy of CT scan in estimation of feasibility of complete cytoreduction in cases of advanced ovarian malignancy. Patients and Methods This study was a collaborative work between the Gynecologic Division, Shatby Maternity University Hospital, and Department of Diagnostic Imaging, University of Alexandria. The study was a prospective study of fifty patients presenting with stage III epithelial ovarian tumors attending Shatby Maternity University
& Ahmed Mohammed Samy El-Agwany
[email protected] 1
Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Hospital, Alexandria University, after taking a written consent and approval of Ethics Committee. Results The study included patients whose ages ranged from 22 to 76 years. Sixty-eight percent of the patients in this study were postmenopausal ([50 years), while 32 % of them were below the age of 50 years. The mean patient age was 50.92 years. Eighty-eight percent of patients had CA125 levels elevated above 35 IU/ml, and only 12 % had CA125 levels below 35 IU/ml. CA125 levels ranged from 10.8 to 5000 IU/ml, and its mean level was 756.10 IU/ml. There was weak correlation between levels of CA125 and total CT PCI score. There was weak correlation between levels of CA125 and total surgical PCI score. There were a strong and statistically significant correlation between the results of CT PCI and surgical PCI (the gold standard) in overall (total PCI) and abdominal-pelvic regions (0–8) and in small bowel and mesentery region (9–12). Sensitivity and specificity were higher for abdomino-pelvic regions (0–8) which showed higher sensitivity and specificity of 90 and 95 %, respectively, compared to small bowel and mesentery region (9–12) which showed slightly lower sensitivity and specificity of 88 and 90 %, respectively. Keywords Ovarian malignancy Imaging PCI CT Peritoneum
Introduction The prognosis for ovarian cancer patients is poor, particularly when the disease is diagnosed in its later stages. Symptoms are ambiguous and often misdiagnosed [1, 2] so the majority of patients are only identified in the advanced stages of the disease. Ovarian cancer is therefore often referred to as the ‘Silent Killer’ [1–15].
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Peritoneal carcinomatosis has always been regarded as a terminal condition. It is present in 10–30 % of patients with gastrointestinal cancer at the time of their initial surgery and is a frequent finding in patients who develop recurrent cancer. Important natural history studies establish a 6-month median survival in this group of patients [15, 16]. Ovarian cancer cells are carried by peritoneal fluid throughout the abdomen and pelvis, resulting in widespread metastases. The fluid follows a circulation pathway from the pelvis to the diaphragm that is defined by the reflections of the peritoneum [17–21]. Peritoneal carcinomatosis ‘PC’ is a common metastasis location for many tumor variances with high incidences occurring in ovarian, gastric and colorectal cancers. In the literature, the occurrence frequencies for peritoneal metastases in ovarian, gastric and colorectal cancers amount to 71, 17 and 10 %, respectively. Due to its natural history, PC is commonly associated with weak prognosis [22–41]. The outcomes of PC diagnosis and prognosis are primarily dependent on the parameters of tumor spread, localization and lesion size. Exact determinations of these parameters are therefore of clinical importance for determining and improving common prognosis and therapy planning. In clinical practice, it is of importance to decide which therapy regime to choose, and it is furthermore important to find out whether a patient has to be excluded from a certain therapy regime or not. Patients with a PCI over 6 are regarded not to be appropriate for CRS [40]. Contrast-enhanced abdomino-pelvic CT scan is a frequently used preoperative radiologic imaging modality to diagnose cancer within the abdominal cavity [40]. In former research, the efficacy of CT diagnosing PC is not well established with an unknown size of implants being detected reliably. Earlier work on CT of peritoneal malignancy was devoted to the detection of disease. More recent studies analyzing the size of implants record varying sensitivities of 63–90 % and specificities of up to 100 % for the diagnosis of peritoneal metastasis. However, in further work, sensitivities range from 41 to 79 % and specificities are observed of up to 100 % [31– 40]. A commonly applied regime for the quantification of the extent of PC and its deposits is the peritoneal cancer index (PCI) developed by Jacquet and Sugarbaker [31]. Today the PCI is acknowledged by research and used for determining therapeutic measures. It serves as an independent prognostic indicator for long-term outcomes in PC. The PCI is calculated as the sum of numerical lesion scores assigned to 13 abdomino-pelvic regions. The aim of the work was to compare CT scan to laparotomy in calculation of peritoneal cancer index (PCI)
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in cases of advanced ovarian cancer and to assess accuracy of CT scan in staging of ovarian cancer.
Patients This study is a collaborative work between the Gynecologic Oncology Division, Shatby Maternity University Hospital, and Department of Diagnostic Imaging, University of Alexandria. This prospective study included 50 women presented with advanced (stage III) epithelial ovarian cancer referred from the gynecologic oncology clinic in Shatby Maternity Hospital, Alexandria University, for the evaluation of a clinically or sonographically detected ovarian mass, between January 2013 and January 2014. Ultrasound (transabdominal and transvaginal) and CT examination of the abdomen and of the pelvis were performed in all patients. The time interval between the two examinations was less than 1 week. The local research ethics committee approved the study, and informed consent was obtained from all patients before the examinations.
Methods All patients were evaluated according to: Detailed History Taking and Patient Examination Details of patient history were taken in details as well as general, abdominal and pelvic examination was performed by the same investigator. Ultrasound Examination Combined transabdominal and transvaginal ultrasound examination was performed using 3.5-MHz abdominal probe and 5-MHz vaginal probe (Fukuda, Denshi, Japan). CA125 Level Levels of CA125 were performed. Its level was measured in (IU/ml). Risk of Malignancy Index (RMI) RMI combines three pre-surgical features: serum CA125 (CA125), menopausal status (M) and ultrasound score (U). The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA125 level (IU/ml). RMI ¼ U M CA125
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•
•
•
The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for ultrasound score of 1) and U = 3 (for an ultrasound score of 2–5). The menopausal status is scored as 1 = pre-menopausal and 3 = postmenopausal The classification of ‘postmenopausal’ is a woman who has had no period for more than 1 year or a woman over 50 who has had a hysterectomy. Serum CA125 is measured in IU/ml and can vary between 0 and hundreds or even thousands of units [9, 32]. All cases were considered for CT scan evaluation.
CT Scan (Multidetector CT, MDCT) and CT Protocols The computed tomographic scan (CT) was performed by the radiology department with consistent experience in gynecologic imaging at the time of performing patient scan. The diagnosis of ovarian malignancy was assessed by the experienced radiologist, together with calculation of peritoneal cancer index (PCI). The CT scans were performed maximum 1 month before surgery on a 16-slice (0.3 cm) multidetector CT machine (Brilliance, Philips, Best, the Netherlands). A single venous phase will be acquired for the abdomen and pelvis starting from above the diaphragmatic cupulae down to the inguinal regions. IV contrast will be injected at a dose of 1.5 ml/Kg body weight, using a mechanical injector at a rate of 3 ml/s. Scanning was started at 65 s from the start of injection. All the examinations were reviewed on a post-processing DICOM workstation for cinematic scrolling and multiplane display. Two individual readers of one radiologist and one surgeon evaluated preoperative contrast-enhanced abdominal CT scans for a population of 50 patients. Patients in the population underwent explorative laparotomy and were suspected to have PC from primary solid tumors. Tumor spread, localization and size were described and documented applying Sugarbaker’s PCI and lesion size schemes in both, radiological and surgical investigations. Radiological observations were retrospectively compared to surgical observations, whereby surgical findings were regarded as the gold standard.
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ovarian cancer. All cases undergone full staging laparotomy. All locations of peritoneal deposits were recorded by the gynecologists together with intra-operative assessment of PCI. The time interval between CT evaluation and surgery is of maximum 1 month. System of Tumor Determination and Description of PCI and LS Score Lesion size was determined by direct visual inspection intra-operatively. It refers to the greatest diameter of the implants within an abdominopelvic region; the diameter of the largest implant is measured and recorded. Implants are scored as lesion 0 through 3 (LS-0 to LS-3). LS-0 means no implants are seen throughout the region; these measurements are taken after lysis of all adhesions and complete inspection of all parietal and visceral peritoneal surfaces. LS-1 refers to implants that are visible up to 0.5 cm in greatest diameter. LS-2 identifies nodules greater than 0.5 cm and up to 5 cm. LS-3 refers to implants 5 cm or greater in diameter. Furthermore, if there was confluence of disease matting abdominal or pelvic structures together, this automatically is scored as LS-3 [29, 31]. Comparison Between CT PCI and Surgical PCI PCI was determined surgically before cytoreduction. All intra-operative findings and PCI scoring were compared retrospectively to those of CT scan. Statistical Analyses Radiological and surgical PCI scores were compared to each other applying the Spearman correlation coefficient to measure inter-rater reliability. All correlations were tested for statistical significance using the p value. Different PCI scores were also evaluated for statistical difference applying the Wilcoxon rank test. In addition to correlation coefficients, both sensitivities and specificities were calculated for the individual abdominal regions as well as lesion size. Statistical analyses were performed using Excel software with Analyse-IT statistical package.
Results Demographic Data
Surgery and Findings
Distribution of the Studied Patients Regarding Age
All surgeries were performed by a team with a particular experience in radical surgical debulking (cytoreduction) for
The study included patients whose ages range from 22 to 76 years; 68 % of the patients in this study were
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postmenopausal ([50 years), while 32 % of them were below the age of 50 years. The mean patient age was 50.92 years.
Table 1 Correlation between the total PCI score by CT scan and surgically
Distribution of the Studied Patients Regarding Obstetric History
Range
•
•
•
Regarding gravidity, 36 % of patients were gravida zero (G0), 30 % gravidity was ranging from 1 to 3, 14 % gravidity ranged from 4 to 6, and 20 % gravidity was above 6. Gravidity ranged from 0 to 10 (mean 2.92, SD 3.15). As for parity, 40 % of patients were nulliparous, i.e., para zero (P0), 30 % parity was ranging from 1 to 3, 16 % parity ranged from 4 to 6, and 14 % gravidity was above 6. Parity ranged from 0 to 8 (mean 2.34, SD 2.60). Previous abortions: 90 % of studied patients did not have previous abortions, 8 % had had 1–2 previous abortions, while only 2 % has 3 or more previous abortions (mean 0.18, SD 0.66).
Distribution of the Studied Patients Regarding Level of CA 125 and RMI •
•
CA125 levels: 88 % of patients had CA125 levels elevated above 35 IU/ml, only 12 % had CA125 levels below 35 IU/ml. Ca125 levels ranged from 10.8 to 5000 IU/ml, and its mean level was 756.10 IU/ml (SD 1152.28). RMI values: 84 % of patients had RMI of 250 or above, while only 16 % of them had RMI below 250. RMI ranged from 48.6 to 15,000 with mean of 3466.31 (SD 4088.73).
PCI Index Analysis Results Regarding Total PCI Score •
•
The mean total PCI was 7.30 (SD 8.90) range 0–39 for surgery, while it was 6.98 (SD 8.84) range 0–39 for CT scan. There was very high correlation between radiological (CT) and surgical PCI regarding the total score r 0.882, p value 0.0001* (indicating high level of significance of this result) (Table 1). The overall sensitivity, specificity, PPV and NPV of total PCI score estimation were 89, 91, 88 and 92 %, respectively (values of CT PCI with regard to surgical PCI) (Table 1).
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CT PCI
Surgical PCI
0–39
0–39
Mean
6.98
7.30
SD
8.84
8.90
R
0.882
p
0.0001*
Sensitivity
89.0
Specificity PPV
91.0 88.0
NPV
92.0
SD standard deviation * means statistically significant difference and result
Correlation Between CA 125, RMI and Total PCI Score by CT and Surgically a.
b.
c.
d.
Correlation between CA 125 and total CT PCI: There was weak correlation between levels of CA125 and total CT PCI score r = 0.036, p = 0.822. Correlation between CA 125 and total surgical PCI: There was weak correlation between levels of CA125 and total surgical PCI score r = 0.049, p = 0.781, that might be related to our sample size. Correlation between RMI and total CT PCI: There was weak correlation between levels of RMI and total CT PCI score r = 0.241, p = 0.163, that might be related to our sample size. Correlation between RMI and total surgical PCI: There was weak correlation between levels of RMI and total surgical PCI score r = 0.266, p = 0.122
Sensitivity, Specificity, PPV and NPV of CT Scan in Detecting PCI in the Total Regions, Regions 0–8 and 9–12 In Pearson’s correlation analysis, we found a strong and statistically significant correlation between the results of CT PCI and surgical PCI (the gold standard) in overall (total PCI) as well as and abdominal-pelvic regions (0–8) and in small bowel and mesentery region (9–12). The correlation was 0.882, 0.911 and 0.822, respectively. Regarding sensitivity and specificity of various regions (0–8) and (9–12), sensitivity and specificity were higher for abdomino-pelvic regions (0–8) which showed higher sensitivity and specificity of 90 and 95 %, respectively, compared to small bowel and mesentery region (9–12) which showed slightly lower sensitivity and specificity of 88 and 90 %, respectively.
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Errors in Peritoneal Cancer Index (PCI) Values Calculation
CT Analysis by Abdomino-Pelvic Regions Correlation analyses by abdomino-pelvic region were conducted between the intra-operative findings (gold standard) and the radiologist readings. Results by region show varying correlation coefficients ranging from 0.564 (for region 6) and 0.919 (for region 0). Highest correlation was for region (0) with sensitivity, specificity, PPV and NPV of 90, 94, 92 and 93 %, respectively. Lowest correlation was for region (6) with sensitivity, specificity, PPV and NPV of 68, 72, 70 and 75 %, respectively. Other regions show varying correlation coefficients, sensitivity, specificity, PPV and NPV but all at a statistically significant difference. Highest correlation, sensitivity, specificity, PPV and NPV were for regions (0), (1) and (7), respectively, as shown in Table 2. Analysis by Lesion Size (LS) Analysis of the finding by LS shows that tumor detection rate is increased with an increase in lesion size and that sensitivities are improved with increasing lesion sizes. Highest tumor detection rate was with LS = 3 (sensitivity 92 %), followed by LS = 2 and LS = 1 with equal sensitivity of 90 %, and lastly LS = 0 with sensitivity of 89 %. So the larger the tumor size, the higher the detection rate (Table 3) sensitivity of CT to LS1 might be related to sample size and small slices of CT.
Table 2 Results by abdomino-pelvic regions including correlation coefficient, p value, sensitivity, specificity, PPV and NPV Correlation
p value
Sensitivity
Specificity
PPV
NPV
1
0.881
0.001*
89.0
90.0
85.0
91.0
2
0.832
0.001*
84.0
82.0
80.0
Upper
3
0.757
•
Mean absolute difference (i.e., the mean of absolute values of differences between surgery PCI and CT PCI):
The error in PCI estimation was calculated by CT scan in different regions. The error was largest for regions 0–8 (1.4), and the least for regions 9–12 (0.82). •
Errors in estimation of total PCI scores:
In total PCI scores, 52 % of cases the radiologist readings were identical to those of during surgery, 22 % were overestimated, and 26 % were underestimated (Table 4). •
Errors in estimation of PCI scores in regions 0–8 and 9–12:
In PCI scores for regions 0–8, 70 % of cases the radiologist readings were identical to those of during surgery, 14 % were overestimated, and 18 % were under estimated. While for PCI scores in regions 9–12, 90 % of cases were identical to those of during surgery, 6 % were overestimated, and 4 % were underestimated.
Discussion In our study, the correlation between radiological and intraoperative finding is very high with a correlation coefficient around 0.882. All correlations were statistically significant at p values below 0.001. Table 3 Sensitivity, specificity, PPV and NPV of CT in relation to the tumor mass LS
Sensitivity
Specificity
PPV
NPV
85.0
0
89.0
85.0
87.0
86.0
1
90.0
87.0
88.0
90.0
0.002*
81.0
79.0
82.0
81.0
2
90.0
86.0
87.0
91.0
8
0.852
0.001*
84.0
83.0
80.0
86.0
3
92.0
88.0
89.0
89.0
0
0.919
0.001*
90.0
94.0
92.0
93.0
4
0.834
0.001*
84.0
85.0
81.0
85.0
LS lesion size, PPV positive predictive value, NPV negative predictive value
7
0.892
0.001*
88.0
91.0
85.0
90.0
6
0.564
0.008*
68.2
72.0
70.0
75.0
5
0.719
0.0032*
72.0
82.0
75.0
80.0
Middle
Lower
Small bowel 9 0.688
0.0031*
69.0
72.0
70.0
75.0
10
0.748
0.0026*
76.0
78.0
75.0
77.0
11
0.672
0.0041*
68.0
72.0
70.0
75.0
12
0.712
0.0021*
72.0
81.0
75.0
82.0
* means statistically significant difference and result
Table 4 Errors in estimation of total PCI scores Number
Percent
No difference
26
52.0
Over estimation
11
22.0
Sub estimation
13
26.0
Range of difference Mean
0–7 1.23
SD
1.87
SD standard deviation
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Notable are correlation coefficients of single regions that are below 0.882 and range between 0.564 and 0.881 compared to an overall PCI correlation of 0.882. This suggests that the PCI, as summation of the observations in the 13 regions, could be misleading due to its aggregating effect. Through this summation, potential individual differences in observations could compensate each other leading to an overall lower PCI difference. Evaluations of the PCI scores are depending on the expertise and experience of the radiologist and surgeon. In this study, we evaluated our CT readings by only one radiologist. Duhr et al. evaluated CT PCI results by two radiologists. They found a very high correlation between two radiologist readings with high inter-rater reliability between both radiologists of 0.953 and 0.913 at p values below 0.001 [40]. A study by Coakley et al. in which preoperative CT scans of patients with ovarian carcinoma were reviewed by three independent readers showed that the depiction of peritoneal metastases is good to excellent. The kappa value in his study ranged between 0.75 and 0.91 which indicates good-to-excellent inter-observer agreements [41]. This study shows an overall sensitivity of 90 % and specificity of 95 % which are broadly in line with more recent studies. Studies by Duhr et al., Coakley et al. and Tempany et al. [42] showed sensitivities of 94, 85 and 93 %, respectively, in the detection of peritoneal metastases in patients with ovarian cancer [40, 42]. Correlation was analyzed by abdomino-pelvic regions ranging from 0.564 and 0.881 at statistically significant levels. Highest correlation was for region (0) with sensitivity, specificity, PPV and NPV of 90, 94, 92 and 93 %, respectively. Lowest correlation was for region (6) with sensitivity, specificity, PPV and NPV of 68, 72, 70 and 75 %, respectively. Other regions show varying correlation coefficients, sensitivity, specificity, PPV and NPV but all at a statistically significant difference. Highest correlation, sensitivity, specificity, PPV and NPV were for regions (0), (1) and (7), respectively. Duhr et al. found higher correlations in upper and middle abdomino-pelvic regions compared to lower region and small bowel. Upper and middle abdomen-opelvic regions in their study showed higher sensitivities and specificities above 86 and 73 %, respectively, compared to the lower region [40]. The best evaluated regions were the central region (0) with 90 % sensitivity, right upper (1) with 89 % and right lower (7) with 88 % sensitivities. These results are broadly in line with Duhr et al. and more recent studies. They showed that most accurately evaluated regions were regions (4), (8), (7) and (5) with sensitivity of 100, 96, 96 and 93 %, respectively [40]. The regions 9–12 (small bowel and mesentery) showed sensitivity and specificity of 88 and 90 %, respectively.
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This results show higher detection rate than most of recent studies which showed that CT scan was less appropriate for diagnosing the small bowel region. In line with our study, Konigsrainer et al. [43] showed sensitivity of 80 % and specificity of 88 % in the regions 9–12 which were the lowest among studied regions. On the contrary, Duhr et al. [40] showed that lowest sensitivity of 50–70 % of this region. The study by Koh et al. also shows sensitivities of 8–14 % in the small bowel region which can also be found in a study by de Bree et al. [44, 45]. The improvement of sensitivities in this study is expected to be a result of the application of a single-center setup with a highly standardized CT acquisition protocol. Furthermore, CT scans in this study were performed with oral and intravenous fillings and reconstruction. It seems probable that a standardized CT acquisition protocol leads to better results in detection rates. It is shown that the PCI score is depending on lesion size. With increasing lesion size, the sensitivity is improving. In our study, the sensitivity increases from 90 % for LS = 1 and LS = 2–92 % for LS = 3. The same findings were reported by Konigsrainer et al. [43]. They showed that the tumor detection rate is improved with increased lesion size it was as low as 65 % for LS = 1, more as 85 % for LS = 2 and 98 % for LS = 3. Similar finding was documented by Duhr et al. [40]. Coakley et al. investigated sensitivities in relation to lesion size and showed 25–50 % lower sensitivities for lesion sizes below 1 cm compared to overall observed sensitivities between 85 and 93 %, thereby suggesting lower performance of CT for small lesion sizes [6]. Accordingly, the low CT accuracy reported by previous studies was possibly caused partially by the use of older CT technology using only axial scans on film for scoring. Also, all examinations were performed using the same state-of-the-art multidetector CT (MDCT) technology to obtain thin sections throughout the whole abdomen/pelvis for detection of subcentimeter implants and generation of high-resolution multiplanar images, which potentially improves detection accuracy. The increasing improvement of results could be due to the further development of new technology such as the contrast-enhanced spiral CT including the multidetector CT or the multimodal reconstruction. Other imaging modalities had been studied for the detection of PC. The FDG-PET (2-fluor-2-deoxy-D-glucose positron emission tomography) is another alternative method but showed low specificities between 54 and 86 %. FDG-PET also shows lower accuracy for the detection of smaller lesion sizes compared to MRI and CT [46–51]. Konigsrainer et al. found that dual-modality FDG-PET/CT achieved the highest overall sensitivity of 88 % for detecting PC and offered the best results for predicting intra-operative tumor load (r2 = 0.904). Comparison with
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intra-operative PCI showed a significant correlation (p \ 0.01) between PET/CT and open staging during surgery. This also was true for the subgroups representing different anatomic regions, including the small bowel. The 63 % overall sensitivity of FDG-PET alone in their study was significantly inferior to that of CT and combined PET/ CT [43]. Although PET/CT showed superior tumor detection rate than CT alone (although tumor detection rate is higher for PET/CT (88 %), it is not significantly higher than that of CT alone (84 %)), and this imaging modality is coasty and not always available in all imaging centers making such limitation of its use. This study (in line with previous studies in the literature) shows that CT is an effective imaging modality for the preand postoperative staging of patients. The good correlation of CT PCI with surgical (intra-operative) PCI may help the surgeon preoperatively to estimate the tumor load and facilitate patient selection for peritonectomy. So, CT with a dedicated protocol and experienced readers may provide a practicable alternative for evaluating the extent of PC. CT PCI correlates well with intra-op PCI and in your study, and accuracy was because of experienced radiologist and summation effect. Using PCI as a tool for the evaluation of extent of peritoneal involvement in ovarian cancer is important. Using PCI is not yet universal among gynecologic oncologist, and the FIGO staging system has a limitation in the evaluation of peritoneal involvement. Using the PCI gives an objective estimate of the extent of disease, and using a CT PCI gives a good roadmap for the surgeon prior to the surgery. Besides, using this objective method of evaluation of disease extent helps in comparing different studies and may also be used as a tool for risk stratification in future studies. Compliance with ethical standards Conflict of interest The authors have nothing to disclose and declare no conflict of interest, whether personal or financial. Ethical approval We have complied with the APA ethical principles regarding research with human participants and/or care in the conduct of the research presented in this article. Informed consent Consents were taken from patients for participation in the study and publishing data.
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Ahmed Samy Elagwany lecturer and assistant consultant of Obstetrics and Gynecology, Faculty of Medicine, Alexandria, Egypt. He has authored many publications in gynecologic oncology, pelvic floor surgery and minimal invasive surgery. Website: https://www. researchgate.net/profile/Ahmed_El-agwany https://alex.academia. edu/ahmedelagwany http://scholar.google.com.eg/citations?user= xocPlbwAAAAJ&hl=en.
