Kavita Mishra

All Publications

• A randomized trial comparing perioperative pelvic FLOor physical therapy to current standard of care in transgender Women undergoing vaginoplasty for gendER affirmation: the FLOWER Trial. International urogynecology journal Ferrando, C. A., Mishra, K., Grimstad, F. W., Weigand, N. W., Pikula, C. 2023

  Abstract

  There are sparse data on the use of postoperative pelvic floor physical therapy (PFPT) in patients undergoing vaginoplasty. The primary objective of this study was to compare the impact of PFPT on the ease of vaginal dilation after vaginoplasty in transgender women. We hypothesized that patients undergoing PFPT would report better ease of vaginal dilation following surgery.This was a randomized trial of transgender women undergoing vaginoplasty. Patients were randomized to either no PFPT or PFPT 3 and 6 weeks following surgery. Subjects completed the Pelvic Floor Disorders Inventory and the Pelvic Floor Impact Questionnaire at baseline and at 12 weeks. At 12 weeks, subjects underwent vaginal length measurement and completed the Patient Global Impression of Improvement and a visual analogue scale (0-10) for ease of vaginal dilation and pain with dilation. A total of 17 subjects in each arm were needed to detect a significant difference in ease of dilation between the two groups.Forty-one subjects were enrolled and 12-week data were available for 37 subjects (20 PFPT, 17 no PFPT). Mean age and BMI were 31 ± 13 years and 24.9 (± 4.0) kg/m2. Subjects were on hormone therapy for a median of 39 (20-240) months and 5 (13.5%) patients had undergone previous orchiectomy. At 12 weeks, the median vaginal length was 12.5 (10-16) cm, reported mean ease of dilation was 7.3 (± 1.6), and pain with dilation was 2.4 (± 1.7). There were no differences in these outcomes or in pelvic floor symptoms between the groups.In this study, routine postoperative PFPT did not improve outcomes in patients undergoing vaginoplasty.

  View details for DOI 10.1007/s00192-023-05623-0

  View details for PubMedID 37688620

  View details for PubMedCentralID 5673826

• Postoperative adverse events following gender-affirming vaginoplasty: an ACS NSQIP Study. American journal of obstetrics and gynecology Mishra, K., Ferrando, C. A. 2023

  Abstract

  As a part of gender-affirming care, many transgender women undergo vaginoplasty surgery, which is increasingly being performed in the United States. There are significant knowledge gaps about adverse events associated with vaginoplasty as the majority of published papers report single-center results.To describe severe and overall 30-day adverse events following gender-affirming vaginoplasty using a large multicenter database.This is a retrospective cohort study of transgender women who underwent vaginoplasty between 2011 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were initially identified by diagnosis codes for gender identity disorders and procedure codes for male-to-female vaginoplasty. Adverse events at 30 days were identified, including unplanned re-operation or readmission, blood transfusion, wound dehiscence, surgical site infections, thromboembolic disease, sepsis, cerebrovascular or cardiac events, and urinary tract infection. Surgical procedures were further stratified by Clavien Dindo Grade, a standardized classification system for registering surgical complications. A score of 0 is given if there are no adverse events, while scores of 1 and 2 refer to deviations from the normal postoperative course, which may include additional pharmacologic treatment, bedside-managed wound complications, and blood transfusions. Clavien Dindo scores of 3-4 include: surgical intervention or life-threatening complication requiring ICU management. Clavien Dindo score of 5 is given for any complication resulting in death.488 cases were eligible for inclusion in this study. The mean age of the cohort was 37.5 and race distribution was: 71.1% White, 15.2% Black, 5.5% Asian/Pacific Islander, and 8.2% Other. Of the cohort, 18.6% were Hispanic. Surgeries were performed by plastic surgeons (87.9%), urologists (8.6%), gynecologists (1.8%), and other specialists (1.6%). Concurrent non-genital surgery was performed in 17% of cases. Median operative time for all cases was 271 (IQR 214-344) minutes. There were no reported deaths in the 30-day period (Clavien Dindo Grade 5) and 5.5% (n=27) of cases had a Clavien Dindo score of 3-4. On multivariate analysis, body mass index and higher ASA class were associated with higher odds of having a Clavien Dindo 3-4 complication (adjOR 2.9, CI 1.32-4.21, p=0.01 and adjOR 1.23, CI 0.56-2.57, p=0.05, respectively). Wound dehiscence, superficial surgical site infection, or deep surgical site infection occurred in 9% (n=46) of cases. The readmission rate was 4.3% (n=21). Several preoperative factors had higher odds of readmission: body mass index (aOR 9.81, CI 1.77-22.13, p=0.005), higher ASA class (aOR 3.23, CI 1.23-9.03, p=0.003), diabetes (aOR 5.39, CI 1.42-20.45, p=0.006), and hypertension (aOR 3.63, CI 1.26-10.47, p=0.01). The reoperation rate was 4.7% (n=23), with no significant patient factors associated with this complication. Of the reoperations, 68.2% of cases were due to wound problems, vaginal bleeding, or hematoma.In transgender women undergoing vaginoplasty for gender affirmation, severe postoperative complications are rare, occurring in 1 in 20 patients. The majority of patients experience minor or no complications following surgery.

  View details for DOI 10.1016/j.ajog.2023.01.011

  View details for PubMedID 36669553

• Gender Affirmation: Individual writing group members are noted in the Acknowledgment section.The following position statement is meant to iterate our support for gender inclusion of both patients and health care providers. Our goal in writing this document is to be as all-encompassing as possible. Acknowledging the plethora and range of gender-related terminology, we will use "transgender and gender diverse." Urogynecology (Hagerstown, Md.) Ferrando, C., Tucker, L., Harroche, J., Mishra, K., Knoepp, L. R., Grimes, C. L. 2022; 28 (11): 735-737

  View details for DOI 10.1097/SPV.0000000000001268

  View details for PubMedID 36288111

• Pharmacologic therapeutic options for sexual dysfunction. Current opinion in obstetrics & gynecology Burton, C. S., Mishra, K. 2022

  Abstract

  PURPOSE OF REVIEW: Sexual problems are reported by up to 45% of individuals assigned female at birth. Although sexual function is a complex biopsychosocial construct, there are a number of pharmacologic treatment options aimed at addressing the changing vaginal hormonal milieu in postmenopausal individuals and moderating the excitatory and inhibitory aspects of the central nervous system in those with hypoactive sexual desire disorder.RECENT FINDINGS: The last decade has seen an increase in the number and type of pharmacologic treatment options for dysfunction primarily associated with menopause and hypoactive sexual desire disorder. Recent publications and systematic reviews have strengthened the safety data of existing FDA-approved medications as well as off-label therapies.SUMMARY: Pharmacologic treatment with local estrogen and testosterone replacement in postmenopausal individuals and with centrally-acting therapies such as flibanserin, bremelanotide, and testosterone in premenopausal individuals assigned female at birth are safe and can be used to improve sexual desire and sexual satisfaction.

  View details for DOI 10.1097/GCO.0000000000000821

  View details for PubMedID 36036468

• Health inequities within the field of urogynecology. Current opinion in obstetrics & gynecology Boyd, B., Guaderrama, N., Mishra, K., Whitcomb, E. 2022

  Abstract

  PURPOSE OF REVIEW: To summarize some of the most recent evidence on disparities in the prevalence, treatment and outcomes of pelvic floor disorders (PFDs), and to address potential interventions to dismantle these inequities.RECENT FINDINGS: There is a paucity of data on the prevalence and treatment of PFDs in racial minority women. The existing studies are limited and poor quality. These studies suggest that racial and ethnic minorities may be at a higher risk of PFDs, however the epidemiologic data regarding prevalence varies by disorder and at times are conflicting. Nevertheless, the data on treatment and complications is clear. Racial and ethnic minorities are less likely to receive gold-standard treatment and are more likely to experience treatment related complications.SUMMARY: We discuss the lack of racially inclusive research that perpetuates ongoing health inequities.

  View details for DOI 10.1097/GCO.0000000000000818

  View details for PubMedID 36036463

• Editorial introductions CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Blumenthal, P. D., Mishra, K. 2021; 33 (6)

  View details for DOI 10.1097/GCO.0000000000000761

  View details for Web of Science ID 000715391900001

• Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons. AJR. American journal of roentgenology Gurland, B. H., Khatri, G., Ram, R., Hull, T. L., Kocjancic, E., Quiroz, L. H., Sayed, R. F., Jambhekar, K. R., Chernyak, V., Paspulati, R. M., Sheth, V. R., Steiner, A. M., Kamath, A., Shobeiri, S. A., Weinstein, M. M., Bordeianou, L., Members of the Expert Workgroup on Magnetic Resonance Imaging of Pelvic Floor Disorders, Ayscue, J., Basilio, P., Chernyak, V., El Sayed, R. F., Gurland, B., Hall, C., Herrmann, K., Jambhekar, K., Kaiser, A. M., Kamath, A., Khatri, G., Kocjancic, E., Rafatzand, K., Rodriguez, L. M., Mishra, K., Neshatian, L., O'Neill, E., Parlade, A., Paspulati, R. M., Ram, R., Sheth, V., Steiner, A., Syan, R., Traugott, A. 2021: 1-13

  Abstract

  The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

  View details for DOI 10.2214/AJR.21.26488

  View details for PubMedID 34505543

• Racial and Ethnic Differences in Reconstructive Surgery for Apical Vaginal Prolapse. American journal of obstetrics and gynecology Boyd, B. A., Winkelman, W. D., Mishra, K., Vittinghoff, E., Jacoby, V. L. 2021

  Abstract

  BACKGROUND: There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery.OBJECTIVE: To evaluate differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity STUDY DESIGN: This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either a vaginal colpopexy or abdominal sacrocolpopexy (ASC). Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine if race and ethnicity is associated with type of colpopexy (vaginal vs. abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity.RESULTS: A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were a vaginal colpopexy and 10,524 (46%) were an abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2,262 (21%) were performed via laparotomy and 8,262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, 11% Unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (OR 0.82, 95% CI 0.68-0.99 and OR 0.56, 95% CI 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (OR 0.68, 95% CI 0.58-0.79 and OR 0.31, 95% CI 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. Following a colpopexy, African American women were more likely to need a blood transfusion (OR 3.04, 95% CI 1.95-4.73, p=<0.001) and have a deep vein thrombosis/pulmonary embolus (OR 2.46, 95% CI 1.10-5.48, p=0.028), but less likely to present with postoperative urinary tract infections (OR 0.68, 95% CI 0.49- 0.96, p=0.028) compared with White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had a higher odds of developing Grade II complications compared with White women in multivariable models (OR 1.25, 95% CI 1.04-1.51, p=0.02).CONCLUSION(S): There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. Specifically, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. While complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.

  View details for DOI 10.1016/j.ajog.2021.05.002

  View details for PubMedID 33984303

• Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review. American journal of obstetrics and gynecology Jolyn Hill, A., Balgobin, S., Mishra, K., Jeppson, P. C., Wheeler, T. 2., Mazloomdoost, D., Anand, M., Ninivaggio, C., Hamner, J., Bochenska, K., Mama, S. T., Balk, E. M., Corton, M. M., Delancey, J. 2021

  Abstract

  BACKGROUND: Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise.OBJECTIVES: We aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to Terminologia Anatomica, the internationally standardized terminology, and (3) compile standardized anatomic terms for improved communication and understanding.STUDY DESIGN: MEDLINE was searched from inception until April 6, 2018 using 40 search terms relevant to posterior female pelvic and vulvar anatomy. Eleven investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. Eleven textbook chapters were also included. Definitions of all pertinent anatomic terms were extracted for review.RESULTS: In all, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. Terminologia Anatomica has previously accepted 186 of these terms. Based on this literature review, we propose the adoption of 11 new standardized anatomic terms including: 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the current accepted term rectovaginal fascia/septum was identified as controversial and requires further research and definition prior to continued acceptance or rejection in medical communication.CONCLUSION: This study highlights variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. We recommend the use of standardized terminology to improve communication and education across medical and anatomic disciplines.

  View details for DOI 10.1016/j.ajog.2021.02.033

  View details for PubMedID 33705749

• A Collaborative Approach to Multicompartment Pelvic Organ Prolapse. Clinics in colon and rectal surgery Gurland, B., Mishra, K. 2021; 34 (1): 69-76

  Abstract

  Multicompartment pelvic organ prolapse is common yet frequently underreported and unrecognized. Although not life-threatening, the impact on quality of life and daily functioning can be significant. Multidisciplinary evaluation and treatment with specialists in colorectal and female pelvic medicine and reconstructive surgery (FPMRS) help to identify patients who will benefit from surgical treatment of vaginal and rectal prolapse. Both abdominal and perineal combined procedures can be offered to patients with a single operation and concurrent recovery period without increasing complications.

  View details for DOI 10.1055/s-0040-1714289

  View details for PubMedID 33536852

  View details for PubMedCentralID PMC7843949

• Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons. Diseases of the colon and rectum Gurland, B. H., Khatri, G., Ram, R., Hull, T. L., Kocjancic, E., Quiroz, L. H., El Sayed, R. F., Jambhekar, K. R., Chernyak, V., Mohan Paspulati, R., Sheth, V. R., Steiner, A. M., Kamath, A., Shobeiri, S. A., Weinstein, M. M., Bordeianou, L., Members of the Expert Workgroup on Magnetic Resonance Imaging of Pelvic Floor Disorders, Ayscue, J., Basilio, P., Hall, C., Herrmann, K., Kaiser, A. M., Rafatzand, K., Rodriguez, L. M., Mishra, K., Neshatian, L., ONeill, E., Parlade, A., Syan, R., Traugott, A. 2021; 64 (10): 1184-1197

  View details for DOI 10.1097/DCR.0000000000002155

  View details for PubMedID 34516442

• Consensus definitions and interpretation templates for magnetic resonance imaging of Defecatory pelvic floor disorders : Proceedings of the consensus meeting of the pelvic floor disorders consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the international continence society, the American Urogynecologic Society, the international Urogynecological association, and the Society of Gynecologic Surgeons. International urogynecology journal Gurland, B. H., Khatri, G., Ram, R., Hull, T. L., Kocjancic, E., Quiroz, L. H., El Sayed, R. F., Jambhekar, K. R., Chernyak, V., Paspulati, R. M., Sheth, V. R., Steiner, A. M., Kamath, A., Shobeiri, S. A., Weinstein, M. M., Bordeianou, L. 2021

  View details for DOI 10.1007/s00192-021-04955-z

  View details for PubMedID 34505921

• Postoperative complications and recurrence rates after rectal prolapse surgery versus combined rectal prolapse and pelvic organ prolapse surgery. International urogynecology journal Wallace, S. L., Enemchukwu, E. A., Mishra, K. n., Neshatian, L. n., Chen, B. n., Rogo-Gupta, L. n., Sokol, E. R., Gurland, B. H. 2021

  Abstract

  Our primary objectives were to compare < 30-day postoperative complications and RP recurrence rates after RP-only surgery and combined surgery. Our secondary objectives were to determine preoperative predictors of < 30-day complications and RP recurrence.A prospective IRB-approved cohort study was performed at a single tertiary care center from 2017 to 2020. Female patients with symptomatic RP underwent either RP-only surgery or combined surgery based on the discretion of the colorectal and FPMRS surgeons. Primary outcome measures were < 30-day complications separated into Clavien-Dindo (CD) classes and rectal prolapse on physical examination.Seventy women had RP-only surgery and 45 had combined surgery with a mean follow-up time of 208 days. Sixty-eight percent underwent abdominal RP repair, and 32% underwent perineal RP repair. Twenty percent had one or more complications, 14% in the RP-only group and 29% in the combined surgery group (p = 0.06). On multivariate analysis, combined surgery patients had a 30% increased risk of complications compared to RP-only surgery patients (RR = 1.3). Most of these complications were minor (14/17, 82.4%) and categorized as CD I or II, including urinary retention and UTI. Twelve percent of this cohort had RP recurrence, 11% in the RP-only group and 13% in the combined surgery group (p = 0.76). Preoperative risk factors for RP recurrence included a primary complaint of rectal bleeding (RR 5.5) and reporting stools consistent with Bristol Stool Scale of 1 (RR 2.1).Patients undergoing combined RP + POP surgery had a higher risk of complications and equivalent RP recurrence rates compared to patients undergoing RP-only surgery.

  View details for DOI 10.1007/s00192-021-04778-y

  View details for PubMedID 33864476

• Surgical Options for Patients Seeking Gender-Affirming Surgery CURRENT OBSTETRICS AND GYNECOLOGY REPORTS Mishra, K., Wallace, S. L. 2020

  View details for DOI 10.1007/s13669-020-00300-1

  View details for Web of Science ID 000567422600001

• A Collaborative Approach to Multicompartment Pelvic Organ Prolapse CLINICS IN COLON AND RECTAL SURGERY Gurland, B., Mishra, K. 2020

  View details for DOI 10.1055/s-0040-1714289

  View details for Web of Science ID 000567190000003

• Delay in Seeking Care for Pelvic Floor Disorders Among Caregivers FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY Mishra, K., Locci-Molina, N. C., Chauhan, B., Raker, C. A., Sung, V. W. 2020; 26 (7): 458–63

  View details for DOI 10.1097/SPV.0000000000000609

  View details for Web of Science ID 000548840700010

• What to do after a mid-urethral sling fails. Current opinion in obstetrics & gynecology Speed, J. M., Mishra, K. n. 2020

  Abstract

  After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated.Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling.MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.

  View details for DOI 10.1097/GCO.0000000000000658

  View details for PubMedID 32833744

• Surgical approach, complications, and reoperation rates of combined rectal and pelvic organ prolapse surgery. International urogynecology journal Wallace, S. L., Syan, R. n., Enemchukwu, E. A., Mishra, K. n., Sokol, E. R., Gurland, B. n. 2020

  Abstract

  Our primary objective was to determine rectal prolapse (RP) and pelvic organ prolapse (POP) reoperation rates and postoperative < 30-day complications after combined RP and POP surgery at a single institution.This was an IRB-approved retrospective cohort study of all female patients who received combined RP and POP surgery at a single tertiary care center from 2008 to 2019. Recurrence was defined as the need for subsequent repeat RP or POP surgery at any point after the index surgery. Surgical complications were separated into Clavien-Dindo classes.Sixty-three patients were identified, and 18.3% (12/63) had < 30-day complications (55% Clavien-Dindo grade 1; 27% Clavien-Dindo grade 2; 18% Clavien-Dindo grade 4). Of patients undergoing combined abdominal RP and POP repair, no postoperative < 30-day complications were noted in the MIS group compared to 37.5% of those patients in the laparotomy group (p < 0.01). Overall, in those patients who underwent combined RP and POP surgery, the need for subsequent RP surgery for recurrent RP was 14% and the need for subsequent POP surgery for recurrent POP was 4.8% (p = 0.25).In this cohort of women undergoing combined RP and POP surgery, a higher proportion required subsequent RP surgery compared to those requiring subsequent POP surgery, although this was not statistically significant. Almost one-fifth of patients undergoing combined RP and POP surgery experienced a < 30-day surgical complication, regardless of whether the approach was perineal or abdominal. For those patients undergoing abdominal repair, < 30-day complications were more likely in those patients who had a laparotomy compared to those who had a minimally invasive surgery.

  View details for DOI 10.1007/s00192-020-04394-2

  View details for PubMedID 32577789

• Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Current opinion in obstetrics & gynecology Wallace, S. L., Miller, L. D., Mishra, K. 2019

  Abstract

  PURPOSE OF REVIEW: To describe the principles of pelvic floor physical therapy (PFPT), review the evidence for PFPT as a treatment for pelvic floor dysfunction, and summarize the current recommendations for PFPT as a first-line conservative treatment option for pelvic floor disorders.RECENT FINDINGS: Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. Currently, there is conflicting evidence regarding the effectiveness of perioperative PFPT before or after POP and urinary incontinence surgery.SUMMARY: PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness.

  View details for DOI 10.1097/GCO.0000000000000584

  View details for PubMedID 31609735

• The impact of frailty on treatment for overactive bladder in older adults. Neurourology and urodynamics Suskind, A. M., Kowalik, C. n., Quanstrom, K. n., Boscardin, J. n., Zhao, S. n., Reynolds, W. S., Mishra, K. n., Finlayson, E. n. 2019

  Abstract

  To examine the impact of frailty on treatment outcomes for overactive bladder (OAB) in older adults starting pharmacotherapy, onabotulinumtoxinA, and sacral neuromodulation.This is a prospective study of men and women age ≥60 years starting pharmacotherapy, onabotulinumtoxinA, or sacral neuromodulation. Subjects were administered questionnaires at baseline and again at 1- and 3-months. Frailty was assessed at baseline using the timed up and go test (TUGT), whereby a TUGT time of ≥12 seconds was considered to be slow, or frail. Response to treatment was assessed using the overactive bladder symptom score (OABSS) and the OAB-q SF (both Bother and HRQOL subscales). Information on side effects/adverse events was also collected. Mixed effects linear modeling was used to model changes in outcomes over time both within and between groups.A total of 45 subjects enrolled in the study, 40% (N = 18) of whom had a TUGT ≥12 seconds. Both TUGT groups demonstrated improvement in OAB symptoms over time and there were no statistically significant differences in these responses per group (all P-values >.05). Similar trends were found for both OAB-q SF Bother and OAB-q SF HRQOL questionnaire responses. Side effects and adverse events were not significantly different between groups (all P's >.05).Adults ≥60 years of age starting second- and third-line treatments for OAB, regardless of TUGT time, demonstrated improvement in OAB symptoms at 3 months. These findings suggest that frail older adults may receive comparable benefit and similar rates of side effects compared with less frail older individuals.

  View details for DOI 10.1002/nau.24093

  View details for PubMedID 31286561

• Standardized Terminology of Apical Structures in the Female Pelvis Based on a Structured Medical Literature Review. American journal of obstetrics and gynecology Balgobin, S. n., Jeppson, P. C., Wheeler, T. n., Jolyn Hill, A. n., Mishra, K. n., Mazloomdoost, D. n., Dunivan, G. C., Anand, M. n., Mama, S. T., Bochenska, K. n., Lewicky-Gaupp, C. n., Balk, E. M., Lancey, J. D., Corton, M. M. 2019

  Abstract

  To review the published literature and selected textbooks, compare existing usage to Terminologia Anatomica, and compile standardized anatomic nomenclature for the apical structures of the female pelvis.MEDLINE was searched from inception until May 30, 2017 based on 33 search terms generated by group consensus. Resulting abstracts were screened by eleven reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures.From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified of which 184 had Terminologia Anatomica accepted terms. Inclusion of several widely-used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, and presacral) not included in Terminologia Anatomica is proposed. Further, two controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication.This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and promote consistency among multiple academic, clinical, and surgical disciplines.

  View details for DOI 10.1016/j.ajog.2019.11.1262

  View details for PubMedID 31805273

• Evaluation and management of defecatory dysfunction in women CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Pratt, T., Mishra, K. 2018; 30 (6): 451-457

  View details for DOI 10.1097/GCO.0000000000000495

  View details for Web of Science ID 000455903200018

• Evaluation and management of defecatory dysfunction in women. Current opinion in obstetrics & gynecology Pratt, T. S., Mishra, K. 2018

  Abstract

  PURPOSE OF REVIEW: To summarize the current recommendations for the evaluation and management of defecatory dysfunction in women and highlight key relationships between defecatory dysfunction and other pelvic floor disorders, including pelvic organ prolapse, fecal incontinence, and voiding dysfunction.RECENT FINDINGS: Conservative measures including lifestyle modifications, pharmacotherapy, and biofeedback continue to be the mainstay of treatment with newer therapies emerging. Physiologic testing and/or radiologic imaging should be considered for those who fail conservative therapy or are clinically complex. Surgical management is appropriate for carefully selected patients with anatomic causes of defecatory dysfunction. Further research is needed on surgical outcomes and patient expectations.SUMMARY: Pelvic floor disorders, including defecatory dysfunction, have a significant societal impact and are highly prevalent among women. Given its potential complexity, a broader focus is needed when evaluating women with defecatory symptoms and effective treatment may require multidisciplinary care.

  View details for PubMedID 30247166

• Fungal Lumbosacral Osteomyelitis After Robotic-assisted Laparoscopic Sacrocolpopexy. Female pelvic medicine & reconstructive surgery Boyd, B., Pratt, T., Mishra, K. 2018

  Abstract

  Sacral osteomyelitis is a rare complication after robotic sacrocolpopexy, with previous reports of enteric and skin flora as inciting organisms. We report a patient who presented with severe low back pain and fever 6 weeks after a robotic sacrocolpopexy, who was subsequently diagnosed as having lumbosacral discitis and osteomyelitis with thoracic intervertebral extension. Empiric antibiotic therapy was initially administered. After laparoscopic mesh excision and abdominal wash out, Candida albicans was isolated from the excised mesh. Postoperatively, the patient was treated with a 12-month course of oral fluconazole with significant clinical improvement. To our knowledge, this is the second reported case of fungal osteomyelitis, providing further recommendations for the management of postoperative sacral osteomyelitis using a minimally invasive surgical technique and guidance by a multidisciplinary team.

  View details for DOI 10.1097/SPV.0000000000000612

  View details for PubMedID 30059439

• Delay in Seeking Care for Pelvic Floor Disorders Among Caregivers. Female pelvic medicine & reconstructive surgery Mishra, K., Locci-Molina, N. C., Chauhan, B., Raker, C. A., Sung, V. W. 2018

  Abstract

  OBJECTIVE: In 2015, 44 million adults were informal, unpaid caregivers to an adult or child. Caregiving (CG) is associated with poor self-care, higher depression rates, and decreased quality of life. Our primary objective was to determine if CG is associated with a delay in seeking care for pelvic floor disorders (PFDs).METHODS: We performed a cross-sectional survey of new urogynecology patients from September 2015 to January 2016. Subjects completed the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, Patient Reported Outcomes Measurement Information System-Depression surveys, and a survey of care-seeking practices. Caregiving was defined as considering one's self a primary caregiver and assisting with 2 or more activities and instrumental activities of daily living. Multiple logistic regression identified variables associated with delayed care-seeking for 1 or more year.RESULTS: Two hundred fifty-six patients completed the survey, 82 caregivers (32%) and 174 noncaregivers (NCGs). Sixty-seven percent of caregivers cared for a child and 33% for an adult. There was no difference between caregivers and NCGs in PFD symptom duration, Pelvic Floor Distress Inventory, or Patient Reported Outcomes Measurement Information System depression scores. Caregiving had higher mean Pelvic Floor Impact Questionnaire scores (69.6 vs 51.0, P = 0.02). There was no difference in proportion of patients who delayed care for 1 year or more (42% vs 54%, P = 0.08). A higher proportion of caregivers for an adult waited for 1 year or more (75% vs 42% NCG, P = 0.001). On multiple logistic regression, CG for adults only was associated with delaying care for 1 year or more (adjusted odds ratio, 3.73; confidence interval, 1.33-10.44; P = 0.01).CONCLUSIONS: One third of patients presenting to a urogynecology practice are caregivers. Caregiving for an adult was associated with a delay in seeking care for PFDs.

  View details for PubMedID 30045052

• Prevalence of occult pre-malignant or malignant pathology at the time of uterine morcellation for benign disease INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS Von Bargen, E. C., Grimes, C. L., Mishra, K., Wang, R., Haviland, M. J., Hacker, M. R., Carnevale, J. A., Estes, A. J., Elkadry, E. A. 2017; 137 (2): 123–28

  Abstract

  To determine the prevalence of occult pre-malignant or malignant uterine pathology at the time of laparoscopic surgery with open power morcellation for benign gynecologic disease.The present multicenter, retrospective cohort study included women who underwent open power morcellation for benign indications between January 1, 2007, and February 28, 2014, at three academic medical centers in the USA. The primary outcome was pre-malignant or malignant pathology at the time of open power morcellation, and was determined from the patients' pathology reports.During the study period, 1214 women underwent open power morcellation for benign indications. Similar preoperative characteristics were observed between patients with normal pathology and those with pre-malignant or malignant uterine pathology, including body mass index, parity, hypertension, diabetes, breast cancer, and smoking (all P>0.129). Among patients who underwent open power morcellation, 14 (1.2%) had occult pre-malignant or malignant pathology; 5 (0.4%) women had endometrial adenocarcinoma and 1 (0.1%) had low-grade endometrial stromal sarcoma. There were eight patients with malignant pathology who underwent additional surgical exploration and were disease free at their final clinical visit, with a median follow-up time of 42.0 months (interquartile range 5.0-62.0 months).Endometrial adenocarcinoma and low-grade endometrial stromal sarcoma were rare in the present study and there were no reports of leiomyosarcoma.

  View details for PubMedID 28170091

  View details for PubMedCentralID PMC5934613

• Global Health Interest Among Female Pelvic Medicine and Reconstructive Surgery Fellows JOURNAL OF REPRODUCTIVE MEDICINE Mishra, K., Lopes, V. V., Hampton, B. S. 2015; 60 (11-12): 501-506

  Abstract

  To determine interest in global health (GH) work among Female Pelvic Medicine and Reconstructive Surgery (FPMRS)fellows.An anonymous, online survey was sent to FPMRS fellows in March 2012. All fellows at accredited and nonaccredited U.S. FPMRS programs were eligible. Of at least 123 fellows, 58 (47%) completed the survey and met inclusion criteria. Survey questions included demographics, GH interest and experience, barriers to GH experience, and career goals.Of those 58 fellows, 79% of respondents graduated from Ob-Gyn residencies, 41% were first year fellows, 45% spoke another language fluently, and 62% had previously worked and/or studied in a developing country. Of the respondents 74% desired GH experience during fellowship, 78% desired GH experience after fellowship, and 40% reported seeing themselves integrating GH into their career. Top barriers to GH work in fellowship were lack of elective time (74%), cost (70%), and personal commitments (67%). A total of 39% of respondents said the ability to work in GH somewhat or strongly affected their decision to pursue FPMRS, and 26% said the availability of GH opportunities affected their fellowship rank list. Family (88%), clinical commitments (78%), and cost (67%) were the biggest reported hurdles to future GH work.Nearly three-quarters of FPMRS fellows are interested in GH work in fellowship. Almost half would like to include it in future practice. Barriers in fellowship include elective time, cost, and personal commitments.

  View details for Web of Science ID 000366243600007

  View details for PubMedID 26775458

• Outcomes following treatment for pelvic floor mesh complications INTERNATIONAL UROGYNECOLOGY JOURNAL Unger, C. A., Abbott, S., Evans, J. M., Jallad, K., Mishra, K., Karram, M. M., Iglesia, C. B., Rardin, C. R., Barber, M. D. 2014; 25 (6): 745–49

  Abstract

  Our aim was to determine symptoms and degree of improvement in a cohort of women who presented following treatment for vaginal mesh complications.This study was a follow-up to a multicenter, retrospective study of women who presented to four tertiary referral centers for management of vaginal-mesh-related complications. Study participants completed a one-time follow-up survey regarding any additional treatment, current symptoms, and degree of improvement from initial presentation.Two hundred and sixty women received surveys; we had a response rate of 41.1 % (107/260). Complete data were available for 101 respondents. Survey respondents were more likely to be postmenopausal (p = 0.006), but otherwise did not differ from nonrespondents. Fifty-one percent (52/101) of women underwent surgery as the primary intervention for their mesh complication; 8 % (4/52) underwent a second surgery; 34 % (17/52) required a second nonsurgical intervention. Three patients required three or more surgeries. Of the 30 % (30/101) of respondents who reported pelvic pain prior to intervention, 63 % (19/30) reported improvement, 30 % (9/30) were worse, and 7 % (2/30) reported no change. Of the 33 % (33/101) who reported voiding dysfunction prior to intervention, 61 % (20/33) reported being at least somewhat bothered by these symptoms.About 50 % of women with mesh complications in this study underwent surgical management as treatment, and <10 % required a second surgery. Most patients with pain preintervention reported significant improvement after treatment; however, almost a third reported worsening pain or no change after surgical management. Less than half of patients with voiding dysfunction improved after intervention.

  View details for DOI 10.1007/s00192-013-2282-9

  View details for Web of Science ID 000336388800007

  View details for PubMedID 24318564

• Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study Abbott, S., Unger, C. A., Evans, J. M., Jallad, K., Mishra, K., Karram, M. M., Iglesia, C. B., Rardin, C. R., Barber, M. D. MOSBY-ELSEVIER. 2014: 163.e1–8

  Abstract

  The purpose of this study was to describe the evaluation and management of synthetic mesh-related complications after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP).We conducted a multicenter, retrospective analysis of women who attended 4 US tertiary referral centers for evaluation of mesh-related complications after surgery for SUI and/or POP from January 2006 to December 2010. Demographic, clinical, and surgical data were abstracted from the medical record, and complications were classified according to the Expanded Accordion Severity Classification.Three hundred forty-seven patients sought management of synthetic mesh-related complications over the study period. Index surgeries were performed for the following indications: SUI (sling only), 49.9%; POP (transvaginal mesh [TVM] or sacrocolpopexy only), 25.6%; and SUI + POP (sling + TVM or sacrocolpopexy), 24.2%. Median time to evaluation was 5.8 months (range, 0-65.2). Thirty percent of the patients had dyspareunia; 42.7% of the patients had mesh erosion; and 34.6% of the patients had pelvic pain. Seventy-seven percent of the patients had a grade 3 or 4 (severe) complication. Patients with TVM or sacrocolpopexy were more likely to have mesh erosion and vaginal symptoms compared with sling only. The median number of treatments for mesh complications was 2 (range, 1-9); 60% of the women required ≥2 interventions. Initial treatment intervention was surgical for 49% of subjects. Of those treatments that initially were managed nonsurgically, 59.3% went on to surgical intervention.Most of the women who seek management of synthetic mesh complication after POP or SUI surgery have severe complications that require surgical intervention; a significant proportion require >1 surgical procedure. The pattern of complaints differs by index procedure.

  View details for DOI 10.1016/j.ajog.2013.10.012

  View details for Web of Science ID 000330126100027

  View details for PubMedID 24126300

• Variables Impacting Care-Seeking for Pelvic Floor Disorders Among African American Women FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY Washington, B. B., Raker, C. A., Mishra, K., Sung, V. W. 2013; 19 (2): 98–102

  Abstract

  This study aimed to identify variables impacting care-seeking for pelvic floor disorders (PFDs) among (1) a general population of professional African American (AA) women and (2) professional AA women with prevalent PFD symptoms.A cross-sectional survey of women registered for the 37th National Assembly of the Links, Inc, a volunteer service organization of professional AA women, was conducted. Our de-identified questionnaire addressed several domains including PFD symptoms, history of PFD diagnoses, attitudes regarding PFDs, and help-seeking. We asked what respondents would do if they experienced PFD symptoms and defined our outcome as the response "I would not seek care." Barriers were covariates associated with not seeking care.Of 568 questionnaires distributed, 362 (64%) with complete data were returned; 6.4% (23/362) of respondents reported they "would not seek care" if experiencing a PFD symptom. On logistic regression, attitude that PFDs are a normal part of aging [adjusted odds ratio (AOR), 5.56; 95% confidence interval (CI), 1.46-21.23] and concerns about insurance (AOR, 3.80; 95% CI, 1.39-10.33) were barriers to care-seeking, adjusting for health status and embarrassment about discussing PFDs.Thirty percent (110/362) of women reported having current PFD symptoms. In this subset, only 26% had accessed care. On logistic regression, prolapse symptoms in the previous 3 months and age 65 years or older were negatively associated with not seeking care (ie, were predictors of care-seeking) (AOR, 0.11; 95% CI, 0.02-0.67) and (AOR, 0.17; 95% CI, 0.03-0.85), respectively, adjusting for pelvic floor distress inventory scores.Among educated and insured AA women, attitudes about aging and insurance complexity are barriers to care-seeking for PFDs. In women with current PFD symptoms, recent prolapse symptoms and age 65 years or older were predictors of care-seeking.

  View details for DOI 10.1097/SPV.0b013e31827bfee8

  View details for Web of Science ID 000209178800008

  View details for PubMedID 23442507

• Providers' Perspectives on Provision of Family Planning to HIV-Positive Individuals in HIV Care in Nyanza Province, Kenya AIDS RESEARCH AND TREATMENT Newmann, S. J., Mishra, K., Onono, M., Bukusi, E. A., Cohen, C. R., Gage, O., Odeny, R., Schwartz, K. D., Grossman, D. 2013: 915923

  Abstract

  Objective. To inform an intervention integrating family planning into HIV care, family planning (FP) knowledge, attitudes and practices, and perspectives on integrating FP into HIV care were assessed among healthcare providers in Nyanza Province, Kenya. Methods. Thirty-one mixed-method, structured interviews were conducted among a purposive sample of healthcare workers (HCWs) from 13 government HIV care facilities in Nyanza Province. Structured questions and case scenarios assessed contraceptive knowledge, training, and FP provision experience. Open-ended questions explored perspectives on integration. Data were analyzed descriptively and qualitatively. Results. Of the 31 HCWs interviewed, 45% reported previous FP training. Few providers thought long-acting methods were safe for HIV-positive women (19% viewed depot medroxyprogesterone acetate as safe and 36% viewed implants and intrauterine contraceptives as safe); fewer felt comfortable recommending them to HIV-positive women. Overall, providers supported HIV and family planning integration, yet several potential barriers were identified including misunderstandings about contraceptive safety, gendered power differentials relating to fertility decisions, staff shortages, lack of FP training, and contraceptive shortages. Conclusions. These findings suggest the importance of considering issues such as patient flow, provider burden, commodity supply, gender and cultural issues affecting FP use, and provider training in FP/HIV when designing integrated FP/HIV services in high HIV prevalence areas.

  View details for DOI 10.1155/2013/915923

  View details for Web of Science ID 000215095600035

  View details for PubMedID 23738058

  View details for PubMedCentralID PMC3659431

• Analgesia/Pain Management in First Trimester Surgical Abortion CLINICAL OBSTETRICS AND GYNECOLOGY Meckstroth, K. R., Mishra, K. 2009; 52 (2): 160–70

  Abstract

  Management of pain during abortion is a critical aspect of patient care. Although it is not always possible to offer a range of pain control options in every setting, individualizing pain medications as much as possible for patients' preferences is likely to improve satisfaction with the abortion experience. Evidence suggests that higher volume (at least 200 mg lidocaine) and deeper injections are beneficial for cervical block. Adding intravenous sedation with a moderate dose of fentanyl and midazolam reduces the pain scores. Oral benzodiazepines may improve satisfaction and anxiety. Deep sedation and general anesthesia are important options for women with significant medical conditions or complicated procedures.

  View details for DOI 10.1097/GRF.0b013e3181a2b0e8

  View details for Web of Science ID 000266136400006

  View details for PubMedID 19407522