Acupuncture treatment of postoperative urinary retention in cervical cancer: Systematic evaluation and meta-analysis

Abstract

Background:

To evaluate the efficacy of acupuncture treatment of postoperative urinary retention after cervical cancer using meta-analysis.

Methods:

Computer searches were performed on 8 common Chinese and English databases such as PubMed, EMbase, Web of Science, China National Knowledge Infrastructure, Wanfang (Wanfang Data Knowledge Service Platform), VIP (China Science and Technology Journal Database), China Biomedical Literature Database and Cochrane Library, as well as Clinical Trials for the treatment of urinary retention after cervical cancer with acupuncture. A randomized controlled trial of postoperative urinary retention after cervical cancer from the time of library construction to 01/2024. The quality of the included literature was evaluated using the Cochrane Risk of Bias Assessment Tool. Meta-analysis and risk of bias analyses were performed using RevMan 5.4, regression and sensitivity analyses were performed using Stata 17.0.

Results:

A total of 31 randomized controlled trials with 2179 patients were included in the study. Interventions included filiform needling, embedding needle, electroacupuncture, moxibustion, warm acupuncture, etc. The results showed that acupuncture treatment increased clinical efficiency [relative risk = 1.32, 95% confidence intervals [CI] (1.20, 1.45), P < .00001], reduced residual urine volume [standardized mean difference = −3.21, 95% CI (−4.00, −0.40), P < .00001], and shortened the time to return to spontaneous urination [MD = −1.96, 95% CI (−3.02, −0.91), P = .0003] and indwelling catheter time [mean difference (MD) = −3.76, 95% CI (−5.66, −1.86), P = .0001], and improved maximum urine flow rate [MD = 4.57, 95% CI (0.70, 8.44), P = .02] and bladder compliance [MD = 10.04, 95% CI (8.14, 11.93), P < .00001].

Conclusion:

Acupuncture treatment promotes recovery in patients with postoperative urinary retention after cervical cancer, but high-quality studies need to be included to further compare different acupuncture interventions.

1. Introduction

According to epidemiology, more than 300,000 people die each year from cervical cancer.^[1] Cervical cancer is still the most common cause of gynecological cancer deaths among Chinese women, and the incidence is gradually getting younger.^[2] Surgery is the standard treatment for early-stage cervical cancer,^[3] but postoperative period is often associated with genitourinary complications,^[4–6] such as urinary retention, incontinence, and sexual dysfunction. The prevalence of urinary retention in patients with cervical cancer is 26%, which increases the risk of urinary tract infections, prolongs hospitalization, increases healthcare expenditure and reduces patients’ quality of life.^[7,8] Therefore, it is essential to effectively control postoperative urinary retention in cervical cancer to promote patients’ recovery.

A growing body of research suggests that acupuncture treatment has significant efficacy in improving urinary retention after cervical cancer surgery.^[9–12] Acupuncture treatment has been accepted by more and more patients and medical personnel at home and abroad due to its high safety and few adverse effects. A meta-analysis of the clinical efficacy of electroacupuncture in the treatment of postoperative urinary retention after cervical cancer has been carried out,^[13] and electroacupuncture can shorten the time of indwelling urinary catheter and reduce the risk of urinary tract infection. However, there are many kinds of clinical acupuncture therapies, each with its own characteristics, and there are fewer comparative studies on different acupuncture therapies for the treatment of postoperative urinary retention in cervical cancer. The aim of this study is to provide more systematic evidence-based medical evidence for the treatment of postoperative urinary retention after cervical cancer by systematic evaluation and meta-analysis, and to guide the clinical treatment of postoperative urinary retention after cervical cancer by acupuncture treatment.

2. Materials and methods

2.1. Literature search strategies

Eight common databases, including PubMed, EMbase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang (Wanfang Data Knowledge Service Platform), VIP (China Science and Technology Journal Database) and SinoMed, were systematically searched by computer. We conducted systematic searches in 8 common Chinese and English databases and clinical registry platforms such as Clinical Trials, and set up a database in NoteExpress to collect original clinical studies on acupuncture treatment for postoperative urinary retention in cervical cancer, and the search time was from the establishment of each database to January 08, 2024. The search terms included “uterine cervical neoplasms,” “cervical cancer,” “acupuncture,” “neoplasm, cervix” “cancer of the cervix,” “acupuncture therapy,” “scalp acupuncture,” “umbilical needle,” “embedding needle,” “electroacupuncture,” “warm acupuncture,” “moxibustion,” and “randomized controlled trial.” The search strategy was based on the PICOS principle, and the combination of subject terms and free terms was adopted. Meanwhile, relevant meta-analyses and reviews were traced to supplement the literature, and the specific search strategy is described in the following paper.

2.2. Inclusion criteria

① The study type is randomized controlled trial.

② The study subjects were patients who had successfully completed radical surgery for cervical cancer; clear cytological or histological pathological diagnosis, gender, age, and race were not limited.

③ Interventions: the experimental group used acupuncture alone, or acupuncture on the basis of the control group (including filiform needle, electroacupuncture, warm acupuncture, embedding needle, moxibustion, acupuncture and moxibustion combination, Acupoint injection, acupoint catgut embedding, etc). The control group used non-acupuncture therapy (medication, electrical stimulation, biofeedback training, conventional therapy, conventional therapy includes physical stimulation, and functional training).

④ Outcome indicators: the primary outcome indicators were clinical efficiency (based on the patient’s ability to urinate voluntarily, related symptoms and whether the residual urine volume is <100 mL) and residual urine volume. Secondary outcome indicators: time to resume voluntary urination, indwelling catheter time, maximum urine flow rate, bladder compliance, and maximum bladder capacity.

2.3. Exclusion criteria

① Studies that included participants with other cancers or other diseases.

② Studies whose interventions included the use of non-acupuncture therapies such as herbal medicine, tuina, and electrical nerve stimulation.

③ Quasi-experimental and observational studies, animal studies, qualitative studies, letters, news articles, editorials, and reviews were also excluded.

④ Comparison of different acupuncture methods and comparison of different surgical procedures.

⑤ Multiple repetitive publications.

⑥ Systematic evaluations or meta-analyses related to the topic of this study.

2.4. Literature screening and data acquisition

Literature obtained from the search was imported into NoteExpress software and 2 researchers independently screened and cross-checked the literature against inclusion and exclusion criteria. Articles were first read for title and abstract to exclude articles that did not meet the criteria. Articles that met the inclusion criteria were then further read and those that did not meet the inclusion criteria were excluded. If disagreements arose, they were discussed with a third person to deal with them. Data extraction included: basic information about the study, quality of the study, interventions (type of acupuncture, frequency, and duration of treatment), control measures, and outcome indicators (clinical effectiveness, residual urine volume, time to return to voluntary urination, time to indwelling catheter, maximal urine flow rate, bladder compliance, and maximal bladder capacity).

2.5. Risk of bias assessment and quality evaluation of the literature

The quality of the included literature was evaluated using the Cochrane risk of bias assessment tool. The risk of bias assessment included 7 aspects: random sequence generation, allocation concealment, patient/investigator blinding, blinding of outcome evaluators, completeness of outcome data, selective reporting of outcomes, and other sources of bias; and the quality of the literature was classified into 3 levels: low risk, unclear, and high risk.

2.6. Statistical analysis

Statistical analyses were performed using Revman 5.4 software, and mean difference (MD) or standardized mean difference (SMD) was chosen as the effect indicator for continuous variables, and relative risk (RR) was chosen as the effect indicator for dichotomous variables, and both were described using 95% confidence intervals (CI). If P ≥ .1 and I² ≤ 50%, it suggests that statistical heterogeneity is small, and the fixed-effects model was used for analysis; if P < .1 and I² > 50%, it suggests that heterogeneity is significant, and the random-effects model was used for subgroup analysis. The metareg language command in Stata 17.0 was invoked to interpret the causes of heterogeneity according to the covariates from the study population (year of study, sample size of the study, and procedure), quality of the literature, control measures, and interventions (type of acupuncture, frequency of acupuncture, number of acupuncture sessions, and duration of each treatment session), and when the regression coefficients showed that P ≤ .05, it was possible to determine that the current covariate was the main cause of heterogeneity, then subgroup analyses were reconducted based on the covariates, and sensitivity analyses were performed if necessary. Egeer test was used to detect publication bias, if P > .05, it meant that there might not be publication bias; otherwise, there might not be publication bias. P ≤ .05 was used as the criterion for statistically significant difference.

3. Results

3.1. Literature search and screening results

A total of 1091 documents were initially searched, 421 duplicates were removed by using the software, 474 documents were removed by reading the titles and abstracts, and 162 documents were removed by reading the full text of the remaining 193 documents, and 31 documents were finally included, and the specific literature screening process is shown in Figure 1.

Figure 1.

Literature screening process.

3.2. Basic characteristics of the included literature

A total of 2179 patients were included in the 31 included studies, all of which were located in China. Thirteen of the interventions were electroacupuncture-based,^[14–26] a total of 6 were acupuncture-based, including 4 filiform needle,^[27–30] 2 embedding needle,^[9,31] 4 moxibustion,^[32–35] 1 warm acupuncture.^[36,37] Acupuncture and moxibustion combined treatment total 4 items, 2 filiform needle combined with moxibustion,^[38,39] 1 ear pressure bean combined with moxibustion,^[40] 1 electroacupuncture combined with moxibustion,^[41] 2 other acupuncture treatments, 1 acupoint injection-based,^[42] 1 acupoint buried threads.^[43] Clinical effectiveness was reported in 26 of the outcome indicators.^{[9,15–21,23–26,28–31,33–38,40–43]} There are 19 articles on residual urine volume,^{[9,14,17,18,20,22–24,27–33,35,38,40,41]} 3 articles reporting the time to return to voluntary urination,^[23,29,39] 7 reports on the duration of indwelling urinary catheters,^{[14,17,18,28,31,32,38]} maximum urinary flow rate was reported in 5 articles,^{[20,24,28,30,33]} 4 articles reporting on bladder compliance,^{[14,29,32,33]} maximum bladder capacity was reported in 3 articles.^[24,28,29] See Table 1 for more details.

Table 1.

Basic characteristics of the included literature.

Abbreviation	Sample size (control group/experimental group)	Control group measures	Experimental group measures	Course of treatment (d)	Frequency	Ending indicators
Chen XL 2023	42/42	Conventional therapy	C + M	7	Moxibustion 7 Zhuang/acupoint;qd	②④⑥
Chen HP 2023	41/41	Conventional therapy	C + E	30	q4h	①②
Su 2022	32/32	Conventional therapy + biofeedback training	C + F	14	25 min, bid	①②③⑥⑦
Cao 2022	33/34	Conventional therapy + electrical stimulation	C + E	83	40 min, qod	②④⑥
Tang 2020	19/20	Conventional therapy + electrical stimulation	C + F	10	25 min, bid	①②③⑤
Zhu 2020	50/50	Conventional therapy	C + E	14	12 h, qd	①②④
Luo 2019	33/33	Conventional therapy + medication	C + F	21	30 min, qd	①②④⑤⑦
Zhang 2019	70/119	Conventional therapy	C + F + M	15	Moxibustion 7 Zhuang/acupoint, qd	③
Lin 2018	41/38	Conventional therapy + electrical stimulation	C + M	15	qd	①②
Sun 2018	42/42	Conventional therapy	C + E	/	30 min, qd	①②③
Dong 2018	40/40	Conventional therapy	C + E	/	40 min, qd	①②④
Guang 2017	39/39	Conventional therapy	C + M	7	15 min, bid	①②⑤⑥
Hong 2017	25/25	Conventional therapy	C + OA	1	qd	①
Lu 2016	30/30	Conventional therapy + medication	E + M	7	30 min, bid	①②
Zhao 2015	30/30	Conventional therapy + medication	C + E	20	30 min, qd	①②⑤⑦
Lin 2014	20/20	Conventional therapy	C + E	5	60 min, qd	①②⑤
Xiang 2013	37/39	Conventional therapy	C + M + EPB	7	Moxibustion 10 min/point, auricular point q2h pressing, 3 min/time, qd	①②
Hu 2013	27/25	Conventional therapy	M	/	Moxibustion 7 3–5 Zhuang/acupoint, 20 min	①
Hu 2012	19/39	Conventional therapy	C + E	6	30 min, qd	①②④
Jia 2012	30/30	Medication	W	7	30 min, qd	①
Liu 2012	14/18	Conventional therapy	C + F	5	30 min, qd	②
Pan 2012	30/30	TDP	C + E	5	30 min, qd	①
Chen 2011	31/30	Electrical stimulation	E	5	40 min, qd	①
Zhou 2010	33/35	Conventional therapy	E	5	20 min, bid	①
Qiu 2009	31/31	Conventional therapy	C + E	5	30 min, qd	②
Li 2009	27/25	Conventional therapy	E	1	30 min, qd	①
Chen 2006	30/30	Conventional therapy + medication	E	5	30 min, bid	①
Li 2006	30/32	Conventional therapy	C + OA	5	qd	①
Zhou 2003	34/40	Medication	E	5	30 min, qd	①
Xie 2001	41/49	Conventional therapy	W	7	30 min, qd	①
Sun 2000	30/62	Conventional therapy	C + F + M	5	Acupuncture 15 min, moxibustion 20–30 min, qd	①②④

① Clinical effective rate; ② residual urine volume; ③ recovery of spontaneous urination time; ④ indwelling catheter time; ⑤ maximum urinary flow rate;⑥ bladder compliance; ⑦ maximum bladder capacity; q2h: once every 2 h; q4h: once every 4 h; qd: once a day; qod: once every other day; bid: twice a day.

C = control group measures, E = electroacupuncture, E = embedding needle, EPB = ear pressure bean, M = moxibustion, OA = other acupuncture treatments, PS = filiform needle, TDP = specific electromagnetic spectrum therapy, W = warm acupuncture.

3.3. Literature quality scores

In terms of selection bias in the included studies, 9 used the randomized table of numbers method,^{[9,18,23,28–30,33,35,43]} and 4 were simple randomized,^{[16,26,32,34]} which were judged to be at low risk of bias, while 15 did not describe the specific randomization method,^{[14,15,20–22,24,25,27,31,36–38,40–42]} so the risk of selection bias was unclear. Three did not mention randomization,^[17,19,39] so they were judged to be at high risk of bias. None of the 31 included studies mentioned allocation and concealment schemes, so the risk was unclear. Intervention modalities such as electroacupuncture, filiform needle, embedding needle, warm acupuncture, and moxibustion were judged to be at high risk because they could not be easily concealed. Blinding of outcome evaluators was not mentioned in any of the 31 studies, so it was judged to be unclear. Among the reporting bias, 2 studies had patients dropped out of follow-up,^[30,35] the details of the number and reasons, and the remaining studies had no lost patients, so they were judged to be at low risk. Thirty-one studies had complete and nonselective reporting of outcome indicators, so they were judged to be at low risk. None of the included studies described the presence of other risks, so they were all evaluated as unclear, as detailed in Figure 2.

Figure 2.

Risk assessment for inclusion in the literature.

3.4. Results of meta-analysis

3.4.1. Clinical effectiveness rate

Twenty-six studies^{[9,15–21,23–26,28–31,33–38,40–43]} reported clinical efficacy rates, and the heterogeneity results showed a more significant inter-study heterogeneity (P < .00001, I² = 77%), and using a random-effects model, the results showed that the experimental group was more able to improve clinical efficacy than the control group [RR = 1.32, 95% CI (1.20, 1.45), P < .00001]. Based on the data situation, it was hypothesized that the source of heterogeneity might be different acupuncture modalities, and therefore subgroup analyses were conducted according to the classification of acupuncture modalities. The 23 papers were classified into filiform needle, electroacupuncture, moxibustion, warm acupuncture, acupuncture and moxibustion combination, embedding needle, and other interventions. Based on the subgroup analysis, the heterogeneity within the different groups was reduced and the choice of acupuncture modality largely influenced the results of meta-analysis. Filiform needle^[28–30] [RR = 1.18, 95% CI (1.05, 1.33), P = .005], electroacupuncture^{[15–21,23–26]} [RR = 1.38, 95% CI (1.14, 1.68), P = .001], moxibustion^{[22,33–35,41]} [RR = 1.42, 95% CI (1.07, 1.87), P = .01], warm acupuncture^[36,37] [RR = 1.47, 95% CI (1.22, 1.77), P < .0001], acupuncture and moxibustion combination^[38,40] [RR = 1.59, 95% CI (1.28, 1.98), P < .0001] interventions were statistically significant compared with the control group, embedding needle^[9,31] and other interventions^[42,43] were not statistically significant when compared with the control group, as detailed in Figure 3.

Figure 3.

Meta-analysis of the clinical effectiveness rate of acupuncture in the treatment of postoperative urinary retention in cervical cancer.

3.4.2. Residual urine volume

Nineteen studies^{[9,14,17,18,20,22–24,27–33,35,38,40,41]} reported residual urine volume and heterogeneity results showed significant between-study heterogeneity (P < .00001, I² = 96%) using a random-effects model. The results showed that residual urine volume was less in the experimental group than in the control group [SMD = −3.21, 95% CI (−4.00, −0.40), P < .00001], filiform needle^[27–30] [SMD = −1.17, 95% CI (−1.64, −0.70), P < .00001], electroacupuncture^{[14,17,18,20,22–24]} [SMD = −2.74, 95% CI (−3.91, −1.58), P < .00001], moxibustion^[32,33,35] [SMD = −7.14, 95% CI (−11.14, −3.13), P < .0005], acupuncture and moxibustion combination^[38,40,41] [SMD = −1.26, 95% CI (−1.87, −0.65), P < .00001] were statistically significant interventions compared to the control group, and filiform needling^[9,31] showed no statistically significant difference compared to the control group, as detailed in Figure 4.

Figure 4.

Meta-analysis of residual urine volume in patients with postoperative urinary retention after acupuncture treatment for cervical cancer.

Due to the significant heterogeneity, the influencing factors of heterogeneity were explored from multiple perspectives by meta-regression analysis, and it was found that the duration of each treatment was the main influencing factor of high heterogeneity, as shown in Table 2. Subgroup analysis was performed based on this result, and it was found that the duration of each treatment was significantly reduced when it was 20 to 30 minutes (P = .32, I² = 0%). It still reduced residual urine volume in patients with postoperative urinary retention after cervical cancer [SMD = −0.81, 95% CI (−1.21, −2.41), P < .0001], as shown in Figure 5.

Table 2.

Meta-regression analysis of residual urine volume in postoperative urinary retention after acupuncture treatment for cervical cancer.

Covariates	Literature	P	95% CI
Year of study	19	.28	[−0.53, 0.17]
Study sample size	19	.74	[−0.07, 0.05]
Study quality score	19	.27	[−5.95, 1.75]
Surgical procedure	15	.82	[−6.64, 5.34]
Control measures	19	.36	[−0.71, 1.85]
Type of acupuncture	19	.25	[−0.56, 2.01]
Frequency of acupuncture	18	.92	[−3.51, 3.89]
Number of acupuncture sessions	14	.65	[−0.31, 0.20]
Duration of each treatment	14	<.0001*	[−0.03, −0.02]

^*PS: differences are statistically significant.

Figure 5.

Subgroup analysis of residual urine volume in postoperative urinary retention after acupuncture treatment for cervical cancer.

3.4.3. Time to return to voluntary urination

Three studies^[23,29,39] reported time to return to voluntary urination, with heterogeneity results showing significant between-study heterogeneity (P = .003, I² = 82%) using a random-effects model. The results showed that the time to return to voluntary urination was shorter in the experimental group than in the control group [MD = −1.96, 95% CI (−3.02, −0.91), P = .0003]. Due to the high heterogeneity, sensitivity analysis was used and found that Zhang 2019^[39] had a more significant effect on the heterogeneity, and after exclusion, the heterogeneity of the remaining 2 articles was significantly reduced (P = .18, I² = 43%), and based on the random-effects model the effect sizes were combined, and the results found that acupuncture treatment was superior to conventional treatment in restoring the time to voluntary urination [MD = −1.47, 95% CI (−2.27, −0.67), P = .0003], as shown in Figures 6 and 7.

Figure 6.

Meta-analysis of the time to return to voluntary urination in patients with postoperative urinary retention after acupuncture treatment for cervical cancer.

Figure 7.

Sensitivity analysis of time to return to voluntary urination in patients with postoperative urinary retention after acupuncture treatment for cervical cancer.

3.4.4. Duration of indwelling urinary catheters

Seven studies^{[14,17,18,28,31,32,38]} reported indwelling urinary catheter time, with heterogeneity results showing significant heterogeneity (P < .00001, I² = 93%) using a random-effects model. The results showed that indwelling catheter time was shorter in the experimental group than in the control group [MD = −3.76, 95% CI (−5.66, −1.86), P = .0001]. Due to the significant heterogeneity, by dividing the control measures into subgroup analyses of conventional treatment^{[14,17,31,38]} and conventional treatment combined with others (biofeedback, herbal hot amniotic packs)^[18,28,32] there was less inter-study heterogeneity in both the conventional treatment group (P = .30, I² = 17%) and the conventional treatment combined with others group (P = .28, I² = 14%), and acupuncture treatment was significantly better than the control group in shortening the indwelling catheter time in patients with postoperative urinary retention after cervical cancer, as shown in Figure 8.

Figure 8.

Subgroup analysis of the duration of indwelling urinary catheter in patients with postoperative urinary retention after acupuncture treatment for cervical cancer.

3.4.5. Maximum urine flow rate

Five studies^{[20,24,28,30,33]} reported maximum urinary flow rate and the heterogeneity results showed significant heterogeneity (P < .00001, I² = 98%) using a random-effects model. The results showed that electroacupuncture [MD = 5.82, 95% CI (0.61, 11.04), P = .03] and moxibustion [MD = 7.50, 95% CI (6.23, 8.77), P < .00001] had a higher maximal urinary flow rate than the control group, and there was no significant difference in filiform acupuncture compared to the control group [MD = 1.80, 95% CI (−5.24, 8.85), P = .62] as detailed in Figure 9.

Figure 9.

Meta-analysis of maximum urinary flow rate in patients with postoperative urinary retention after acupuncture for cervical cancer.

3.4.6. Bladder compliance

Four studies^{[14,29,32,33]} reported Bladder compliance, with heterogeneity results showing low between-study heterogeneity (P = .55, I² = 0%) using a fixed-effects model. The results showed that moxibustion [MD = 9.96, 95% CI (7.95, 11.96), P < .00001], millimeter acupuncture [MD = 19.38, 95% CI (4.52, 34.24), P < .00001], and electroacupuncture [MD = 9.15, 95% CI (2.88, 15.42), P < .00001] treatments of bladder compliance was higher than the control group [MD = 10.04, 95% CI (8.14, 11.93), P < .00001], as detailed in Figure 10.

Figure 10.

Meta-analysis of bladder compliance in patients with postoperative urinary retention after acupuncture treatment for cervical cancer.

3.4.7. Maximum bladder capacity

Three studies^[24,28,29] reported maximum bladder capacity and heterogeneity results showed significant between-study heterogeneity (P < .00001, I² = 94%) using a random-effects model. The results showed no statistically significant difference in maximum bladder capacity between the experimental and control groups [MD = 21.19, 95% CI (−21.86, 64.25), P = .33], as detailed in Figure 11.

Figure 11.

Meta-analysis of maximal bladder capacity in patients with postoperative urinary retention after acupuncture treatment for cervical cancer.

3.5. Publication

Bias was analyzed by the clinical effectiveness rate of the most included literature, and the results showed that the result of Egeer quantitative test was P < .05, suggesting that there might be a publication bias, as shown in Figure 12.

Figure 12.

Publication bias analysis of the clinical effectiveness of acupuncture for the treatment of postoperative urinary retention in cervical cancer.

4. Discussions

In 2022, there will be 296,300 new cases of female cancer and 104,900 deaths in China, of which cervical cancer has the highest incidence and mortality rate,^[44] and although its incidence has been effectively controlled by screening and human papillomavirus vaccination,^[45] Bayesian modeling predicts that China will still face a huge cervical cancer burden in the next decade.^[46] Surgery is the main clinical treatment modality, and urinary retention is a major complication after cervical cancer surgery, which increases the risk of urinary tract infection, prolongs hospitalization, and increases disease variability. Postoperative urinary retention after cervical cancer is one of the common complications, and most of the current treatments start from health education,^[47] nursing interventions,^[48] pelvic floor functional exercises,^[49] and neuroelectric stimulation.^[50–52]

In this paper, we searched for the effects of acupuncture-related treatments on postoperative urinary retention in cervical cancer. Starting from different acupuncture modalities, we explored their effects on postoperative urinary retention in cervical cancer. The present results show that acupuncture treatment is more advantageous than conventional treatment in terms of clinical efficiency, and filiform needle, electroacupuncture, moxibustion, acupuncture and moxibustion combination, and warm acupuncture are also superior to conventional treatment, while the difference between embedding needles, acupuncture-point embedded threads, and acupuncture-point injections is not statistically significant, and buried needles, acupuncture-point injections, and acupuncture-point embedded threads are belonging to the special needles stabbing method, and the literature of its related research is relatively small, with an insufficient sample size, and the results are unstable. According to the subgroup analysis, different acupuncture treatment modalities may be one of the sources of its heterogeneity. Meta-analysis results show that acupuncture treatment can shorten the time of resumption of spontaneous urination and the time of indwelling urinary catheter, which greatly reduces the risk of complications such as urinary tract infections.^[7] The subgroup analysis of indwelling catheter time found that the control measures may be a significant influence factor of heterogeneity, suggesting that the control measures should be strictly regulated at the beginning of the experimental design in the future. Acupuncture and moxibustion treatment is an important part of Chinese medicine, which includes a variety of treatment modalities, such as electroacupuncture, warm acupuncture, filiform needles, embedding needles, acupoint plasters, and acupoint injections. Different acupuncture methods have their own advantages for the treatment of diseases. Electroacupuncture is the use of needles into the acupoints to get gas, on the needle to (inductive) bioelectricity of the body’s trace current wave. warm acupuncture involves placing moxa pillars at the end of the needle after needling, lighting them so that their heat is transmitted to the body through the body of the needle. filiform needles is stabbing acupoints with a millipede needle. The above treatments are generally 5 to 7 days for a course of treatment. Moxibustion refers to placing moxa floss or other medicines on the body surface of the acupoints parts of the burning, warming and ironing, borrowing moxibustion fire’s mild heat as well as the action of the medicine, through the meridian conduction, in order to achieve the therapeutic effect. acupoint injections is a therapeutic method of injecting medicinal solution into acupoints to prevent and treat diseases. It can combine the stimulation of needling with the properties of the drug and its penetration into the acupuncture point to exert its comprehensive effect. Acupuncture-point embedding is a therapeutic method in which absorbable sheep’s intestinal threads are embedded in the corresponding acupoints through sterile needles, and the tissues around the acupoints are utilized to absorb the threads, creating a continuous stimulating effect. Therefore, the therapeutic efficacy of acupuncture therapy is affected by a variety of factors, such as the treatment modality, acupoints, duration of needle retention, and frequency of treatment. During the treatment of the disease, if we can choose the right way will be more conducive to the recovery of the disease.

Meta-analysis of acupuncture treatment of postoperative urinary retention in cervical cancer has also been conducted in previous studies, but the outcome indicators were limited to the analysis of clinical effectiveness,^[53,54] or only studies of the effect of electroacupuncture on it were carried out,^[13] and the sample sizes were small. In this paper, residual urine volume and bladder compliance, maximal urine flow rate, and maximal bladder capacity in urodynamics were used as the outcome indexes to more objectively and comprehensively judge various acupuncture treatments for postoperative urinary retention in cervical cancer. Measurement of residual urine volume is an important indicator for judging voiding function, and the results showed that acupuncture, filiform needle, electroacupuncture, moxibustion, and combined acupuncture were superior to conventional treatment in reducing residual urine volume, but the difference was not statistically significant for buried needles. Meta-regression analysis found that the time of each treatment was a significant influencing factor of the heterogeneity of the residual urine volume, and that the duration of the treatment time was an important factor influencing the effect of acupuncture,^[55] and therefore the effect of acupuncture can be further explore the volume–effect relationship between treatment duration and residual urine volume in post-cervical urinary retention. Urodynamic examination assesses dysfunction of the lower urinary tract and pelvic floor function and provides objective information on pressure measurements, sensorimotor and neurophysiological parameters related to the bladder and pelvic floor. Studies have shown significant changes in bladder compliance, maximal urine flow rate, and maximal bladder capacity in postoperative urodynamics in patients with cervical cancer.^[56,57] Maximum bladder capacity, reflects the capacity at which subjects with normal bladder sensation no longer delay urination. Bladder compliance, another important measurement parameter in cystometry,^[58] is the change in bladder capacity per unit of forced urethral muscle pressure. The results of this study showed that electroacupuncture and moxibustion improved patients’ maximal urinary flow rate and bladder compliance more compared to conventional treatment, and there was no difference in the improvement of maximal bladder capacity. In the case of filiform needle, there was an improvement in bladder compliance and no difference in maximum urinary flow rate compared to conventional treatment. The small number of urodynamics-related indicators in the included literature and the insufficient sample size lead to biased results, which should be added as an outcome indicator in subsequent studies of related diseases.

There are still some limitations in this paper: (1) the quality of the included literature is low, most of the literature only mentioned randomization, but did not describe the randomization method in detail, and did not mention the allocation concealment, and acupuncture as an intervention method is difficult to implement blinding, which is prone to bias; (2) the outcome indicators of the included literature are still mostly based on the clinical effectiveness rate as the main indicator, and some of them are based on the subjective feeling of the patients, and there are fewer literature with objective indicators, such as residual urine volume and urodynamics, as the main outcome indicators; (3) the control group measures are not uniformly conventional treatment, and there are some differences, and urodynamics as the main outcome indicators, there may be some bias.

In conclusion, the current evidence suggests that acupuncture treatment can improve the clinical efficiency of postoperative cervical cancer patients, reduce residual urine volume, shorten the time of resuming voluntary urination and the time of indwelling catheterization, and improve the patients’ maximum urine flow rate and bladder compliance. In addition to this, due to the low quality of this included study, future research should be further strengthened with high-grade evidence on acupuncture treatment for patients with postoperative urinary retention after cervical surgery.

Acknowledgments

The author would like to thank Professor Furui Miao and Yushan Fan for their help in this study.

Author contributions

Conceptualization: Hui Xu, Yushan Fan, Yujun He, Furui Miao.

Data curation: Hui Xu, Yushan Fan, Zibin Wang, Furui Miao.

Formal analysis: Hui Xu, Fangzhi Zhang, Yujun He, Yu Wu.

Funding acquisition: Yushan Fan, Furui Miao.

Investigation: Zibin Wang, Fangzhi Zhang, Yu Wu.

Methodology: Hui Xu, Zibin Wang, Fangzhi Zhang, Yujun He, Yu Wu, Furui Miao.

Project administration: Hui Xu, Zibin Wang, Yujun He, Yu Wu.

Resources: Zibin Wang, Yujun He.

Software: Zibin Wang, Fangzhi Zhang, Yujun He, Yu Wu.

Supervision: Fangzhi Zhang.

Validation: Hui Xu, Zibin Wang, Yu Wu, Furui Miao.

Visualization: Fangzhi Zhang, Yujun He, Yu Wu, Furui Miao.

Writing – original draft: Hui Xu, Yushan Fan.

Writing – review & editing: Yushan Fan, Furui Miao.