Surgical Treatment Of Women Research Articles

Age‐related trends in female stress urinary incontinence surgery in Australia – Medicare data for 1994–2009

Urinary incontinence has a high burden of suffering in Australia. There has been a significant shift towards less invasive surgery for stress urinary incontinence (SUI) over the last 15 years. Elderly women are underrepresented in surgical treatment of SUI. To identify patterns in the surgical treatment of women with SUI in Australia from January 1994 to December 2009. Gender- and age-specific data from Medicare Australia between January 1994 and December 2009 were extracted. Surgical procedures were identified using Medicare Benefit Schedules codes. Pattern of SUI surgery was analysed during the 15-year period. Using data from Medicare Australia, we reported trends in female SUI surgery across Australia from 1994 to 2009. The overall number of female SUI operations has increased, almost doubling over a 3-year period following the introduction of the midurethral sling (MUS). The per capita rate increase in all SUI surgery is most prominent in women over the age of 55 years increasing 87%, compared with only 1% in younger women over the 15-year period. MUS have overtaken Burch Colposuspension as the most popular operation for female SUI across all age groups, accounting for 85.5% of all procedures performed in 2009 with 14 MUS for every one colposuspension. Stress incontinence procedures performed in Australia have almost doubled with the introduction of the MUS with the greatest increase in women aged over 55 years. MUS has overtaken the Burch Colposuspension as the most popular operation for stress urinary incontinence for women in Australia.

Surgical Treatment for Women with Breast Cancer: Do Randomized Clinical Trials Represent Current Medical Practices?

Randomized clinical trials have not shown survival differences between breast cancer patients who undergo breast-conserving surgery and those who undergo modified radical mastectomy (MRM). Recent studies however, have suggested that these randomized clinical trials findings may not be representative of the entire population or the nature of current patient care. A retrospective analysis of female invasive breast cancer patients who underwent surgery in the Surveillance, Epidemiology, and End Results database (1990-2003) was performed. Survival was compared amongst women who underwent partial mastectomy, partial mastectomy plus radiation (PMR), or MRM. Cox proportional hazards regressions were used to investigate the impact of method of treatment upon survival, after adjusting for patient and tumor characteristics. A total of 218,043 patients, mean age 62 years, were identified. MRM accounted for 51.5 per cent of the study population whereas PMR accounted for 34.9 per cent. On multivariate analyses, significant improvement was observed in patient survival associated with PMR when compared with MRM patients (hazard ratio = 0.71, 95% confidence interval = 0.67-0.74, P < 0.001). This population-based study suggests that there is a survival benefit for women undergoing PMR in the treatment of breast cancer.

The future of gynaecological endoscopy: from the work presented in the Free Communications during the ESGE Meeting in Florence October 2009

The senior author has had the privilege, along with almost 2,000 other delegates, of visiting the extraordinary ESGE meeting in Florence recently. The size of the turnout suggests that there is much going well in the field of gynaecological surgery. Minimal access techniques are now being used in every inhabited continent and in every type of health care system. There are more and more doctors of every nationality, colour and religion coming together with the single aim of improving the outcomes of surgical interventions in women. Reviewing the more than 400 talks, videos and posters presented at the ESGE meeting clearly demonstrates how minimal access techniques may be used for virtual every surgical intervention in gynaecology. We were also privileged to see enormous trade exhibitions with literally hundreds of new refined tools and devices, all designed to make surgically easier, more acceptable and above all safer for our patients. Whilst self-evidently good, this excess of technological virtuosity brings with it major concerns. The very number and variety of these advanced technologies can, in fact, be rather overwhelming. Many of these devices are extraordinarily expensive and in these difficult financial times it is ethically essential that, irrespective of the type of health care system in which we practice, we develop systems that not only work but work cost-effectively. With this concept in mind, we present here our personal review of some of the presentations from this important meeting. 1. Improved imaging techniques. From the first video laparoscopies, there has been a steady and dramatic improvement in the quality of the images we have. Better light sources and cameras have replaced dull, poorly illuminated pictures by images of consistent high quality. Three-chip cameras are now standard and increasingly high-definition systems are becoming available. The results of these technological advances were demonstrated by the extraordinary quality of many of the videos shown throughout the meeting. This is an area which is perhaps difficult to justify on formal cost effect analysis but in which there can be no compromise. To undertake surgery with inadequate vision is both impractical and unethical. Conversely, the better the image available, the better the definition of the anatomy and pathology and so the more precise and better the quality of the surgery should be. The images are now so good it is difficult to anticipate further meaningful improvements but it is probable that further miniaturisation will make the instruments easier to use, particularly in areas currently difficult to access. Three-dimensional imaging would also simplify dissection and suturing. Such systems have been tried previously but have been found to be heavy and difficult to use and to also produce unstable and nausea-producing images. It is likely that improvements in these systems may soon result in the wide availability of useful 3-D imaging systems. 2. Entry techniques. From the earliest days of laparoscopic surgery the safest and best method of entry into the abdominal cavity has been a matter of controversy. The data has been recently reviewed and extensively commented on in this journal (Sutton). Because of the relative infrequency of serious entry-related injury it has not been possible to do large enough trials to prove R. Garry (*) 94 Westgate, Guisborough TS14 6AP, UK e-mail: raygarry@btinternet.com

Acupuncture for uterine fibroids.

Uterine fibroids (UFs) are benign growths within the uterine muscle and are present in 30% of women during their reproductive years. With the exception of hysterectomy, there are no effective medical and surgical treatments for women with uterine fibroids . Acupuncture is an ancient Chinese method which has been used for both the prevention and treatment of diseases for over three thousand years. There are many types of acupuncture used to manage UFs, with body acupuncture being the most commonly used. The literature reporting the benefits or harms of acupuncture for the management of UFs has not yet been systematically reviewed. To assess the benefits and harms of acupuncture in women with uterine fibroids The following electronic databases were searched 21st May 2009: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; the Menstrual Disorders and Subfertility Group's Specialised Register of Trials; Chinese Biomedical Literature Database (CBM); Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS); Chinese Medical Current Contents (CMCC) and China National Knowledge Infrastructure(CNKI). Citation lists, experts in the field and grey literature were also referred to. No restrictions such as language were applied. All randomised controlled trials (RCTs) comparing acupuncture management with placebo acupuncture, no management, Chinese medication, Western medication or other managements of uterine fibroids were considered for inclusion. Acupuncture management included either traditional acupuncture or contemporary acupuncture, regardless of the source of stimulation (for example, body, electro, scalp, elongated, fire, hand, fine needle, moxibustion). Acupuncture management without needling was excluded. Two review authors assessed trial risk of bias according to our a priori criteria. No trials were included in this version of the review, therefore no data was collected. No randomized double-blind controlled trials met the inclusion criteria . The effectiveness of acupuncture for the management of uterine fibroids remains uncertain. More evidence is required to establish the efficacy and safety of acupuncture for uterine fibroids.There is a continued need for well designed RCTs with long term follow up.

Three-dimensional power Doppler ultrasound in ovarian cancer and its correlation with histology

The aim of this study was to evaluate and quantify intraovarian blood flow with 3D power Doppler histogram analysis before surgical intervention in women suspected of having ovarian carcinoma and to determine the correlation with histology findings. A prospective study was designed and 17 consecutive patients undergoing oophorectomy were included. Two groups of women were evaluated: high-risk women for ovarian pathologies and low-risk women with no known ovarian disease scheduled for bilateral oophorectomy for nonmalignant related pathology. Transvaginal ultrasound was performed using 2D, 3D-power Doppler ultrasound and histogram techniques. Four main parameters were evaluated: vascularization index (VI), flow index (FI), vascularization-flow index (VFI) and mean grayness (MG). Histological confirmation of the findings was done in all patients. Data were analyzed by the Mann-Whitney U test with P<0.05 considered as significant. Ultrasound scanning was performed for a total of 24 ovaries: 9 ovaries with cancer and 15 controls. There were no significant differences between the groups in all four histogram measurements: FI, VI, VFI and MG. There were no differences between the groups regarding ultrasound findings of free fluid in pelvis (16.7% in women with malignancy, 18.2% in women without ovarian malignancy; P=0.938) and the presence of complex ovarian cyst (83.8% in women with malignancy, 36.4% in women without ovarian malignancy; P=0.131). No significant differences were noted between benign and malignant ovaries in our population in all four indices of vascularity and perfusion of 3D power Doppler. Further large prospective studies should evaluate the significance of 3D power Doppler using histogram analysis in the early detection of ovarian cancer.

Laparoscopic Segmental Resection for Rectum and/or Sigmoid Endometriosis Improves Patient's Pain and Quality of Life

Study Objective: Symptoms of bowel endometriosis including intestinal subocclusion or acute occlusion, constipation, diarrhea, pain and bleeding in faeces during menstrual flow are harmful for the patient's quality of life. The objective of this study was to assess the impact of laparoscopic surgical treatment in women with bowel endometriosis on their quality of life and painful symptoms.

Trends in Surgical Management of Stress Urinary Incontinence Among Female Medicare Beneficiaries

To identify patterns in the surgical treatment of women with stress urinary incontinence in the United States from 1992 to 2001. As a part of the Urologic Diseases in America Project, we analyzed data from a 5% national random sample of female Medicare beneficiaries aged > or =65 years. The data were obtained from the Centers for Medicare and Medicaid Services carrier and outpatient files from 1992, 1995, 1998, and 2001. Women in the sample with a diagnosis of urinary incontinence were identified using the International Classification of Diseases, 9th edition, codes. Surgical procedures were identified using the Current Procedural Terminology, 4th edition, codes. The patterns of care were then analyzed during the 10-year period. The overall number of surgical procedures increased from 18 820 to 32 480 during the 10-year period, likely owing to the growing population of Medicare beneficiaries. Needle suspension was the most commonly performed incontinence procedure in 1992 and 1995. Collagen injections gained rapid popularity and became the most common procedure by 1998. A drastic increase in the numbers and rates of sling placements occurred from 1995 to 2001. A rapid shift occurred in the surgical management of stress urinary incontinence in the 1990s. The rapid increase in the use of sling procedures corresponded with a decrease in the use of the many other available anti-incontinence procedures. As in previous years, we identified a trend toward minimally invasive approaches to surgery, without the presence of randomized controlled clinical trials to support these trends. We anticipate that the analysis of Medicare claims from 2004 onward will demonstrate an additional increase in the use of sling procedures.

Determinants of fatigue 6 and 12 months after surgery in women with early-stage breast cancer: A comparison with women with benign breast problems

Objective The objective of this study was to examine the predictors of fatigue 6 and 12 months after surgical treatment in women with early-stage breast cancer (BC group) and in women with benign breast problems (BBP group) in a prospective follow-up study. Methods Women entered the study prior to diagnosis and completed questionnaires on personality factors, psychological factors, and social support. Fatigue was assessed 6 and 12 months after diagnosis (BBP group) or surgical treatment (BC group). Clinical data were taken from medical records. Results In the BC group ( n=117), fatigue at 6 months was predicted by trait anxiety ( P<.001) and extraversion ( P<.05). Trait anxiety ( P<.05), extraversion ( P<.05), and depressive symptoms ( P<.05) predicted fatigue at 12 months. In the BBP group ( n=190), the predictors were trait anxiety ( P<.001) for fatigue at 6 months, and trait anxiety ( P<.001) and neuroticism ( P<.01) for fatigue at 12 months. Conclusion Many patients who are already fatigued before diagnosis remain tired regardless of diagnosis. Trait anxiety is strongly related to fatigue in both groups.

Surgical intervention for stress urinary incontinence: comparison of midurethral sling procedures.

The synthetic, tension-free midurethral sling was introduced in the 1990s as a surgical treatment for women with stress urinary incontinence (SUI). Several similar products are now available. The authors generated data comparing clinical outcomes of two midurethral sling procedures. To compare clinical outcomes of two midurethral sling procedures currently used for the treatment of women with SUI: Gynecare Tension-free Vaginal Tape (TVT; Ethicon Women's Health & Urology, Somerville, NJ) and Uretex Self-Anchoring Urethral Support System (CR Bard Inc, Covington, Ga). A nonrandomized, prospective study was conducted at a urogynecology practice with women who had preoperative urodynamically proven SUI. The study consisted of two phases: 100 consecutive cases using the TVT midurethral sling, then 100 consecutive cases using the Uretex midurethral sling. Symptom improvement was evaluated at 12-month postoperative follow-up by measuring rates of prolonged intermittent self-catheterization, urinary tract infection, urinary retention requiring urethrolysis, and new-onset urge incontinence. The TVT and Uretex groups were similar with respect to age, parity, and incidence of prior anti-incontinence surgery. There was no significant difference in outcomes measured between the two groups in symptom improvement at 12-month follow-up. The TVT and Uretex midurethral slings demonstrate similar short-term improvement and complication rates in a nonrandomized population of women with SUI.

Accuracy and Surgical Impact of Magnetic Resonance Imaging in Breast Cancer Staging: Systematic Review and Meta-Analysis in Detection of Multifocal and Multicentric Cancer

PURPOSE We review the evidence on magnetic resonance imaging (MRI) in staging the affected breast to determine its accuracy and impact on treatment. METHODS Systematic review and meta-analysis of the accuracy of MRI in detection of multifocal (MF) and/or multicentric (MC) cancer not identified on conventional imaging. We estimated summary receiver operating characteristic curves, positive predictive value (PPV), true-positive (TP) to false positive (FP) ratio, and examined their variability according to quality criteria. Pooled estimates of the proportion of women whose surgery was altered were calculated. Results Data from 19 studies showed MRI detects additional disease in 16% of women with breast cancer (N = 2,610). MRI incremental accuracy differed according to the reference standard (RS; P = .016) decreasing from 99% to 86% as the quality of the RS increased. Summary PPV was 66% (95% CI, 52% to 77%) and TP:FP ratio was 1.91 (95% CI, 1.09 to 3.34). Conversion from wide local excision (WLE) to mastectomy was 8.1% (95% CI, 5.9 to 11.3), from WLE to more extensive surgery was 11.3% in MF/MC disease (95% CI, 6.8 to 18.3). Due to MRI-detected lesions (in women who did not have additional malignancy on histology) conversion from WLE to mastectomy was 1.1% (95% CI, 0.3 to 3.6) and from WLE to more extensive surgery was 5.5% (95% CI, 3.1 to 9.5). CONCLUSION MRI staging causes more extensive breast surgery in an important proportion of women by identifying additional cancer, however there is a need to reduce FP MRI detection. Randomized trials are needed to determine the clinical value of detecting additional disease which changes surgical treatment in women with apparently localized breast cancer.

Changing trends in the laparoscopic management of ectopic pregnancy in a London district general hospital: 7-years experience

SummaryWe set out to evaluate the effect of a programme introduced in January 2003 to make operative laparoscopy the standard surgical treatment for women requiring surgery for ectopic pregnancy. This was a retrospective and prospective clinical data analysis performed at The Whipps Cross University Hospital in London, with a comparison of data taken before and after the introduction of the programme. A total of 116 women who had surgical management for ectopic pregnancy from January 2000 to December 2002 and 313 women who had surgery for ectopic pregnancy between January 2003 and December 2006 took part in the study. A programme was started in January 2003 to make operative laparoscopy the surgical management of choice. The main outcome measure was the proportion of women requiring surgery who had operative laparoscopy in the two study periods. The χ2-test was used to determine if there was any statistically significant difference between proportions. A difference was deemed statistically significant if p < 0.05. The results showed that there was a progressive rise in the proportion of ectopic pregnancies managed by operative laparoscopy following the change in January 2003. A total of 34% of women were managed laparoscopically between 2000 and 2002, increasing to 90% between 2003 and 2006. This difference was statistically significant (p < 0.001). In 2006, some 96% of women requiring surgery were managed by laparoscopic surgery. The findings of this study indicate that it is possible to implement changes which increase and sustain a high rate of laparoscopic surgery for women with ectopic pregnancy requiring surgery in a district general hospital setting.

The Predominant Role of Surgery in the Prevention and New Trends in the Surgical Treatment of Women With BRCA1/2 Mutations

Advances in understanding molecular and genetic mechanisms underlying cancer promise an "individualized" management of the disease. Women with a BRCA1 or BRCA2 germ-line mutation are at very high risk of breast and/or ovarian cancer. Because high-quality data are lacking from randomized trials, prevention strategies and treatment of patients with BRCA-associated breast cancer are complex. The data for this review were obtained by searching PubMed and Medline for articles about optimizing prevention and treating women with familial susceptibility to breast and ovarian cancer. Prophylactic surgery is the rational approach for women who carry the BRCA mutation; chemoprevention and/or intensified surveillance represent alternative approaches. Prophylactic bilateral salpingo-oophorectomy is superior to bilateral prophylactic mastectomy. However, reaching a definitive clinical decision is complex, and several variables should be considered for an individualized approach. Accumulating data support the concept of more extensive surgery for newly diagnosed breast cancer in women with a BRCA mutation but new unbaised studies are needed for an evidence-based approach . Such patients treated with breast conservation therapy for early-stage breast cancer are at higher risk of contralateral breast cancer than noncarriers. Primary bilateral mastectomy could also be considered and discussed with these patients. Breast tumors from BRCA1 mutation carriers are predominantly of basal subtype (i.e., triple negative), and BRCA2 mutation carriers are of luminal subtype (i.e., estrogen receptor positive). Decisions on adjuvant treatment are based on estrogen receptor, progesterone receptor, and HER2 status. The complex management of healthy women and breast cancer patients with familial susceptibility to breast and ovarian cancer requires an individualized prevention or treatment strategy by an experienced team.

Predictors of comprehensive surgical treatment in patients with ovarian cancer

Providing appropriate surgical treatment for women with ovarian cancer is one of the most effective ways to improve ovarian cancer outcomes. In this study, the authors identified factors that were associated with a measure of comprehensive surgery, so that interventions may be targeted appropriately to improve surgical care. Using Healthcare Cost and Utilization Project hospital discharge data from 1999 to 2002 for 9 states, the authors identified 10,432 admissions of women who had an International Classification of Disease, 9th Revision (ICD-9) primary diagnosis of ovarian cancer and who had undergone oophorectomy. Based on National Institutes of Health Consensus Panel recommendations, surgeries were categorized as comprehensive by using ICD-9 diagnosis and procedure codes. Logistic regression analysis using data from 5 states with a full set of variables (n = 6854 patients)was used to identify factors that were associated with the receipt of comprehensive surgical care. Overall, 66.9% of admissions (range, 46.3-80.8% of admissions) received comprehensive surgery. Factors that were associated independently with comprehensive surgical care included age (ages 21-50 years vs ages 71-80 years or > or = 81 years), race (Caucasian vs African American or Hispanic), payer (private insurance vs Medicaid), cancer stage (advanced vs early), annual surgeon volume (low/medium [2-9 surgeries per year] or high [>10 surgeries per year] vs very low [1 surgery per year]), and surgeon specialty (gynecologic oncologists vs obstetrician gynecologists or general surgeons). Among nonteaching hospitals, medium-volume hospitals (10-19 ovarian cancer surgeries per year) and high-volume hospitals (> or = 20 surgeries per year) had significantly higher comprehensive surgery rates than low-volume facilities (1-9 surgeries per year). Volume did not influence comprehensive surgery rates in teaching hospitals. Many women with ovarian cancer, especially those in poor, elderly, or minority groups, are not receiving recommended comprehensive surgery. Efforts should be made to ensure that all women with ovarian cancer, especially those in vulnerable populations, have the opportunity to receive care from centers or surgeons with higher comprehensive surgery rates.

The Role of the “Team” for Operative Laparoscopy: Emphasis on Instrumentation, Equipment, and Care Before, During, and After Surgery

The role of the operating room ‘‘team’’ before, during and after operative laparoscopy has expanded greatly over the past several decades. Minimally invasive surgical treatments for women have expanded to include a multitude of procedures. Although these treatment advances have expanded, so has the role of operating room personnel. As a result of phenomenal visualization, everyone in the operating room can anticipate, participate, and follow laparoscopic procedures from the simplest to the most intricate. The role of the team is more important than ever. Most would agree, the more efficient the team, the better the surgeon, which, in turn, may be directly correlated to the efficacy of the surgical treatment of the patient and ultimately the potential for improved patient outcomes. There is an important continuum with all types of surgery, and operative laparoscopy is no exception. The efficiency of the ‘‘team’’ is dependent on the continuum of care of the patient beginning with the preoperative period, through surgery, and culminating during the postoperative period. The ‘‘team’’ encompasses everyone involved with the care of the patient before, during, and after surgery. Specifically, in all 3 of these areas the team refers to perioperative nurses (to include preoperative nurses, the circulating nurse or nurses, laser nurse when a laser is used, and recovery room or postanesthesia care unit [PACU] nurses), anesthesiologist or anesthetist, surgeon, surgical assistant, surgical technician, and the person who cleans the instruments as well as anyone else involved in the surgery and care of the patient. The key ingredient for the team to be successful is that all these people who are involved in some manner with the care of the patient (either directly or indirectly) work together through effective communication to provide the patient with the best possible surgical experience. This includes a variety of people in the continuum of overall patient care [1–13].

0545: Trends in Surgical Treatment of Women with Invasive Cervical Cancers

0545: Trends in Surgical Treatment of Women with Invasive Cervical Cancers

In situ methotrexate injection for treatment of recurrent endometriotic cysts

Objective Ovarian endometrioma recurrence is frequent. Conventional treatment of ovarian endometrioma is by surgical cystectomy. We proposed an alternative medical treatment for recurrent ovarian endometrioma: cyst aspiration followed by in situ methotrexate injection. Study design From January 2002 to May 2003, 14 patients with recurrent homolateral ovarian endometrioma underwent transvaginal ultrasound guided cyst puncture and aspiration followed by methotrexate injection, whilst under general anasthesia. Recurrence rate during follow up was evaluated. Results No complication was reported. After a mean follow up of 20 ± 5 month (min: 13, max: 29), four recurrences were diagnosed (28.6%). Two asymptomatic recurrences were not treated and two painful recurrences underwent a second cyst drainage with methotrexate injection. Conclusions In situ methotrexate injection is a simple, effective and an interesting alternative to surgical treatment in women with recurrent homolateral ovarian endometrioma.

Treatment principles of the polycistic ovary syndrome

In the present review principles of therapy and surgical treatment of women with the polycistic ovary syndrome (PCOS) are summarised in compliance with pathogenesis. Different methods of treatment of women with the PCOS for decreasing symptoms of hyperandrogenemia, the recovery of the ovulatory function and treatment of infertility are examined.

Cirugía oncoplástica conservadora en el cáncer de mama. Indicaciones y límites en su aplicación quirúrgica

Conservative surgery is the technique of choice in the surgical treatment of women with breast cancer. The conflict between the extent of resection and the final cosmetic result can lead to asymmetries and deformities that are intensified after adjuvant treatment. The introduction of oncoplastic techniques in the conservative management of breast cancer have allowed the indication for breast conservation to be increased and have improved cosmetic results, increasing the technical alternatives available to general surgeons specialized in breast cancer. The present article aims to review the indications and limitations of these conservative oncoplastic techniques in the surgical management of women with breast cancer.

Endometrial thickness after misoprostol use for early pregnancy failure

Objectives: To assess if there was any potential relationship between endometrial thickness and final treatment outcome in women successfully treated with misoprostol for a first trimester anembryonic gestation, embryonic demise or fetal demise. Methods: Eighty women were treated with up to two doses of misoprostol 800 μg vaginally for early pregnancy failure. Subjects were scheduled to return 2 (range 1–4), 7 (range 5–9) and 14 (range 12–17) days after treatment. Transvaginal ultrasonography was performed at each follow-up visit. Results: The median endometrial thickness at each of the follow-up visits for women who had expelled the gestational sac was 14 mm, 10 mm, and 7 mm, respectively. The endometrial thickness at the first follow-up visit exceeded 15 mm in 20 subjects (36%) and 30 mm in four subjects (7%). Only three women had a suction aspiration for bleeding after documented expulsion. The endometrial thickness for these women was 11, 13, and 14 mm at the first follow-up visit. Conclusions: There is no obvious relationship between increasing endometrial thickness and the need for surgical intervention in women treated with misoprostol for early pregnancy failure.

Influence of surgical intervention on life quality of gynecological patients

For investigation of the influence of surgical intervention on life quality of gynecological patients 72 women were inspected, whose clinical picture had as a leading syndrome the chronic pelvis pain (CPP), and 32 women with womb myoma, who did not complain against a pain in the pelvis. Life quality was evaluated before surgical intervention and in 10-12 months after it.&#x0D; It was detected that due to the big expression of psyching disorders of neurotic level in women with CPPtheir starting level of quality life was considerably lower than in patients with womb myoma.&#x0D; Inspection results manifested that operative treatment led tc improving life quality evaluating in 10-12 months after surgical intervention in women with womb myoma, but did not lead tc changes in majority of patients with CPP.