Electroacupuncture improves bladder and bowel function in patients with traumatic spinal cord injury: results from a prospective observational study

Electroacupuncture for post-stroke urinary incontinence: a systematic review and meta-analysis with trial sequential analysis

Background

The evidence for the effectiveness of electroacupuncture (EA) for post-stroke urinary incontinence (PSUI) patients remains unclear. Therefore, the purpose of this systematic review and meta-analysis was to assess the efficacy of EA for PSUI.

Methods and analysis

Eight English and Chinese databases were searched from their inception until 1 August 2023 to collect randomized controlled trials (RCTs) that investigated the effect of EA on PSUI. Two reviewers independently selected studies that met the eligibility criteria, extracted the necessary data, and assessed the risk of bias for included studies using Cochrane Handbook version 5.1.0. Meta-analysis was performed using Review Manager software (version 5.4.1). Publication bias detection was conducted using STATA (version 16.0). Sequential analysis was performed using TSA 0.9.5.10 Beta. The Grading of Recommendations Assessment, Development, and Evaluation System (GRADE) was used for assessing the certainty of evidence.

Results

We included 15 RCTs involving a total of 1,414 patients. The narrative analysis revealed that compared with sham EA, genuine EA exhibited greater efficacy in reducing occurrences of 24-h urinary incontinence while also enhancing maximum cystometric capacity (MCC). Moreover, this effect remained significant even during the 3-month follow-up period. Fourteen studies were encompassed within the quantitative analysis. In contrast to active interventions, EA did not yield an improvement in the responder rate (RR 1.53, 95% CI 0.61 to 3.80, p = 0.36). When compared with basic treatments, the combination of EA with them led to a reduction in 24-h urinary incontinence occurrences (MD -0.56, 95% CI -0.60 to -0.52, p < 0.00001), an improvement in MCC (MD 43.23, 95% CI 28.86 to 57.60, p < 0.00001), and a decrease in residual urine volume (RUV; MD -19.99, 95% CI -29.75 to -10.23, p < 0.0001). However, it did not lead to an increase in the responder rate (RR 1.39, 95% CI 0.88 to 2.20, p = 0.16). In comparison to basic treatments combined with active interventions, the amalgamation of EA and them led to an increase in the responder rate (RR 1.24, 95% CI 1.14 to 1.35, p < 0.00001), a reduction in 24-h urinary incontinence occurrences (MD -2.90, 95% CI -5.26 to -0.55, p = 0.02), a decrease in International Consultation on Incontinence Questionnaire-Short Form scores, and an improvement in both MCC (MD 42.11, 95% CI 23.26 to 60.96, p < 0.0001) and RUV (MD 42.11, 95% CI 23.26 to 60.96, p < 0.0001). Furthermore, all reported adverse effects associated with EA were mild. The trial sequential analysis suggested that a sufficient sample size was available to yield results. However, the level of evidence was predominantly assessed as low or very low.

Conclusion

Electroacupuncture improved post-stroke urinary incontinence with no serious adverse effects. Caution is warranted due to methodological issues, and more high-quality studies are required to confirm its efficacy and safety.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023449599, Identifier CRD42023449599.

Effects of electroacupuncture on pediatric chronic urinary retention: a case-series study

Objectives

This study aims to preliminarily evaluate the effect and safety of electroacupuncture (EA) in treating pediatric chronic urinary retention (CUR) following lumbosacral surgeries, with treatment duration evaluated.

Methods

This prospective case-series study was performed from August 5, 2017, to July 31, 2022. Pediatric patients diagnosed with CUR following lumbosacral surgeries were included and treated by EA for 2-16 weeks. Responders were defined as participants achieving a reduction of 50% or more in post void residuals (PVR) from baseline. Time-to-event analysis was applied to explore the association between EA treatment duration and response rate. Adverse event was recorded.

Results

Totally 14 participants (mean [SD] age, 12 [4] years) completed EA treatment. Response rate was 71% (10/14) at the 12th week. 50% (7/14) of participants removed catheters at the 12th week, and none of them experienced re-catheterization in the 24-week follow-up. No serious adverse event was reported. Time-to-event analysis estimated that over 50% patients could respond to EA of more than 8 weeks. Subgroup analysis showed that participants with baseline PVR ≥300 ml and CUR duration ≥12 months experienced longer EA duration to reach the response rate of 50%, compared with those whose PVR <300 ml and CUR duration <12 months (median value: 12 weeks vs. 8 weeks, 12 weeks vs. 4 weeks, respectively).

Conclusions

EA could reduce PVR for pediatric patients suffering from CUR following lumbosacral surgeries, with long-term efficacy and safety. EA treatment of more than 8 weeks was reasonable. Further study of a larger sample and controlling is needed.

Clinical Trial Registration

www.chictr.org.cn, identifier, ChiCTR1800020222.

Electroacupuncture at Zusanli (ST36) Repairs Interstitial Cells of Cajal and Upregulates c-Kit Expression in Rats with SCI-Induced Neurogenic Bowel Dysfunction

Background

Electroacupuncture (EA) could improve colonic transit activity in rats with neurogenic bowel dysfunction (NBD) caused by spinal cord injury (SCI). The function of interstitial cells of Cajal (ICCs) and c-Kit expression may play essential roles in this process. Material and Methods. Thirty-six Sprague Dawley rats were randomized to the sham group, the SCI group, or the SCI + EA group (bilateral Zusanli, 30 min/day, 14 days). Changes in the ultrastructural morphology of ICCs were observed. The c-Kit expression on different levels was analyzed by immunohistochemistry, Western blotting, and RT-qPCR, respectively.

Results

Abnormal morphology of ICCs and downregulation of the c-Kit expression occurred after SCI. While the number of ICCs was increased, the ultrastructural morphology was improved significantly in EA rats. They also showed better improvement in c-Kit expression at both protein and gene levels.

Conclusion

Abnormal ICCs in colon tissues and the downregulated expression of c-Kit could be observed after SCI. EA at Zusanli (ST36) could improve the colon function by repairing the morphology and increasing the number of ICCs and upregulating c-Kit expression.

Stem Cell Conditioned Medium Treatment for Canine Spinal Cord Injury: Pilot Feasibility Study

Spinal cord injury (SCI) involves nerve damage and often leads to motor, sensory and autonomic dysfunctions. In the present study, we have designed a clinical protocol to assess the feasibility of systemic delivery of allogenic canine bone marrow tissue-derived mesenchymal stem cell conditioned medium (BMMSC CM) to dogs with SCI. Four client-owned dogs with chronic SCI lasting more than six months underwent neurological and clinical evaluation, MRI imaging and blood tests before being enrolled in this study. All dogs received four intravenous infusions with canine allogenic BMMSC CM within one month. Between the infusions the dogs received comprehensive physiotherapy, which continued for three additional months. No adverse effects or complications were observed during the one, three and six months follow-up periods. Neither blood chemistry panel nor hematology profile showed any significant changes. All dogs were clinically improved as assessed using Olby locomotor scales after one, three and six months of BMMSC CM treatment. Furthermore, goniometric measurements revealed partial improvement in the range of joint motion. Bladder function improved in two disabled dogs. We conclude that multiple delivery of allogenic cell-derived conditioned medium to dogs with chronic SCI is feasible, and it might be clinically beneficial in combination with physiotherapy.

Effects of electroacupuncture on patients with chronic urinary retention caused by a lower motor neuron lesion: An exploratory pilot study

Chronic urinary retention (CUR) is defined as a non-painful bladder that remains palpable or percussible after the patient has passed urine. Acupuncture may decrease PVR and improve bladder function in patients with neurogenic CUR. The aim of this study was to preliminarily observe the effectiveness of electroacupuncture (EA) for patients with CUR caused by a lower motor neuron lesion and to provide some therapeutic data for further study.This study was a pilot study of 30 patients with CUR caused by a lower motor neuron lesion. Patients were treated with EA for 12 weeks with 36 sessions of EA.Responders were defined as participants with a decline in postvoid residual urine (PVR) volume after spontaneous urination of ≥50% from baseline. The proportion of responders, change in PVR volume from baseline after spontaneous urination, and the proportion of patients with severe difficulty with urination, who required assistance with bladder emptying and with stool retention, were measured at weeks 4, 8, and 12.Thirty patients were included in this study, and 23 completed 12 weeks of treatment. The proportion of responders at weeks 4, 8, and 12 was 6.67%, 28%, and 43.48%, respectively. Decrease in PVR volume, compared with baseline, was significant at all asessment timepoints. The proportion of patients with severe difficulty with urination, who required assistance with bladder emptying and with stool retention, decreased after treatment.EA is a potential treatment for improving bladder function in patients with CUR caused by a lower motor neuron lesion.

Treatment of urinary incontinence after total hysterectomy with acupuncture: A case report

RATIONALE

Acupuncture is a significant feature of traditional Chinese medicine, which can dredge the channels, harmonize qi and blood, replenish deficiency and relieve excess, strengthen the body and remove pathogens to treat urinary incontinence after hysterectomy, and improve the quality of life, which is simple, convenient, inexpensive, and practical.

PATIENT CONCERNS

After a total hysterectomy, the catheter was retained every day, causing urinary incontinence and elderly urine wetness for 30 days.

DIAGNOSES

Postoperative urinary incontinence for 1 month; type 2 diabetes for 4 years. Hypertension for 2 years.

INTERVENTIONS

From the first month after operation, acupuncture on bilateral, Ciliao (BL32), Zhongliao (BL33), and Xialiao (BL34).

OUTCOMES

The patient experienced bladder fullness on the 2nd day. On the 3rd day, the patient could arose from bed and urinated on her own. On the 4th day, she could urinate freely. The time and frequency of urination were normal.

LESSONS

acupuncture is safe and effective mode for the treatment of urinary incontinence issues after total hysterectomy. It greatly improves the quality of life and daily wellbeing.

Protective effect of lutein on spinal cord ischemia-reperfusion injury in rats

OBJECTIVES

Paraplegia is deterioration in motor or sensory function of the lower limbs that can occur after modification of a thoracoabdominal aortic aneurysm. The purpose of this survey was to determine the protective action of lutein on spinal cord ischemia-reperfusion (I-R) damage.

MATERIALS AND METHODS

Thirty-five male rats were distributed into five groups: intact, sham, dimethyl sulfoxide (I-R+DMSO), low dose lutein (I-R+0.2 mg/kg lutein), and high dose lutein (I-R + 0.4 mg/kg lutein). Thirty minutes before surgery, a single dose lutein or DMSO was administered to rats of experimental groups. Next, the abdominal aorta was clamped exactly under the left renal artery and proximal to the abdominal aortic bifurcation for 60 min. All animals were evaluated by neurological function and histological and biochemical examinations at 72 hr after I-R.

RESULTS

The mean motor deficit index (MDI) scores in lutein groups were lower compared with the DMSO group (P<0.001). Plasma level of malondialdehyde in lutein groups decreased compared with the DMSO group (P<0.05). Plasma level of total antioxidative capacity was increased in the high lutein group compared with low dose lutein and sham groups (P<0.05). Mean number of normal motor neurons in lutein groups was greater compared with the DMSO group (P<0.001). There was a significant negative correlation between MDI scores and the number of normal neurons (r= -0.764, P<0.001).

CONCLUSION

Findings of the present study demonstrate that lutein may support spinal cord neurons from I-R damage.

Electroacupuncture for Postoperative Urinary Retention: A Systematic Review and Meta-Analysis

Background

This systematic review aimed at summarizing and evaluating the evidence from randomized controlled trials (RCTs) which used electroacupuncture (EA) to treat postoperative urinary retention (PUR).

Methods

We searched thirteen databases electronically through April 2018 without language restrictions. We included RCTs of women with PUR; other types of urinary retention or not-RCTs were excluded. Two independent reviewers extracted studies' characteristics, and disagreements were resolved by consensus. Data were pooled and expressed as standard mean difference (SMD) for continuous outcomes and odds ratio (OR) for dichotomous outcomes, with 95% confidence interval (CI).

Results

We found very low to moderate level of evidence that effects of less than or equal to a week were statistically significant: therapeutic effect improved (OR=4.21; 95%CI [3.04, 5.83]; P<0.00001), residual urine volume decreased (SMD=-13.24; 95%CI [-15.70, -10.78]; P<0.00001), bladder capacity increased (SMD=0.56; 95%CI [0.30, 0.83]; P<0.0001), and urinary flow rate improved (SMD=0.91; 95%CI [0.64, 1.18]; P<0.00001). Effect over a week was statistically significant as well. Therapeutic effect improved (OR=8.29; 95%CI [2.91, 24.25]; P<0.0001), residual urine volume decreased (SMD=-1.78; 95%CI [-2.66, -0.89]; P<0.0001), bladder capacity (SMD=0.92; 95%CI [0.61, 1.23]; P<0.00001) and urinary flow rate (SMD=1.69; 95%CI [0.59, 2.79]; P=0.003) increased, and first urination after surgery was earlier (SMD=-0.92; 95%CI [-1.37, -0.46]; P<0.0001), compared with physical exercise, medication, or no treatment.

Conclusion

The efficacy and safety of EA on key outcomes in women with PUR are statistically significant, but the level of most evidence was very low or low. More large-scale, long-term RCTs with rigorous methodological quality are needed.

Effects of electroacupuncture on bladder and bowel function in patients with transverse myelitis: a prospective observational study

Objective

To preliminarily explore the effect of electroacupuncture (EA) on bladder and bowel dysfunction in patients with transverse myelitis.

Methods

Sixteen participants were treated with EA at bilateral BL32, BL33, and BL35 once a day, five times a week for the first 4 weeks, and once every other day, three times a week for the following 4 weeks. Patients were then followed up for 6 months. Bladder and bowel function, and the safety of EA, were assessed.

Results

After 8 weeks of treatment, five (5/16, 31%) patients resumed normal voiding, three (6/16, 38%) regained partially normal voiding, and five (5/16, 31%) had no change. After treatment, the residual urine volume decreased by 100 mL (IQR 53–393 mL; P<0.05) in nine patients with bladder voiding dysfunction; in 11 patients with urinary incontinence, the number of weekly urinary incontinence episodes, 24-hour urinary episodes, and nocturia episodes per night diminished by 14 (95% CI 5 to 22), 5 (95% CI 1 to 9), and 4 (95% CI 0 to 7) episodes, respectively (all P<0.05). After 8 weeks of treatment in eight patients with faecal retention, four (4/8, 50%) resumed normal bowel movements, three (3/8, 38%) regained partially normal bowel movements, and one (1/8, 13%) had no change.

Conclusions

EA might be a promising alternative for the management of bladder and bowel dysfunction in patients with transverse myelitis. Randomised controlled trials are needed to confirm the effectiveness and safety of EA for this condition.

Spinal Cord Injury: How Could Acupuncture Help?

Spinal cord injury (SCI) is one of the most common causes of death and disability worldwide, and it can result in both permanent disability and serial complications in patients. Research shows that patients with SCI complications are often interested in acupuncture for symptomatic relief. Therefore, the issue of physicians advising their patients regarding the use of acupuncture to alleviate SCI complications becomes pertinent. We review and summarize two types of relevant publications: (1) literature concerning acupuncture for SCI and its complications and (2) underlying mechanisms of acupuncture therapy for SCI. Clinical trials and reviews have suggested that acupuncture effectively manages a range of post-SCI complications, including motor and sensory dysfunction, pain, neurogenic bowel and bladder, pressure ulcers, spasticity, and osteoporosis. The effect of acupuncture on post-SCI orthostatic hypotension and sexual dysfunction remains unclear. Decreased oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, and increased regenerative stem cell production are the possible mechanisms of acupuncture therapy for SCI. Although many limitations have been reported in previous studies, given the evidence for the efficacy of acupuncture, we recommend that physicians should support the use of acupuncture therapy for SCI complications.

Electroacupuncture preconditioning and postconditioning inhibit apoptosis and neuroinflammation induced by spinal cord ischemia reperfusion injury through enhancing autophagy in rats

Electroacupuncture (EA) has beneficial effects on spinal cord ischemia reperfusion (I/R) injury, but the underlying mechanisms are not fully understood. This study aimed to investigate the role of autophagy in the protection of EA preconditioning and postconditioning against spinal cord I/R injury. For this, spinal cord I/R injury was induced by 14min occlusion of the aortic arch, and rats were treated with EA for 20min before or after the surgery. The expression of autophagy components, light chain 3 and Beclin 1, was assessed by Western blot. The hind-limb motor function was assessed using the Basso-Beattie-Bresnahan (BBB) criteria, and motor neurons in the ventral gray matter were counted by histological examination. The apoptosis of neurocyte was assessed by the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) assay. The expression of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and matrix metalloproteinase-9 (MMP-9) was also measured using Western blot or enzyme-linked immunosorbent assay (ELISA). Either EA preconditioning or postconditioning enhanced autophagy, and minimized the neuromotor dysfunction and histopathological deficits after spinal cord I/R injury. In addition, EA suppressed I/R-induced apoptosis and increased in the expression of TNF-α, IL-1β, and MMP-9. In contrast, the autophagic inhibitor (3-methyladenine, 3-MA) inhibited the neuroprotective effects of EA. Moreover, 3-MA increased the apoptosis and the expression of TNF-α, IL-1β, and MMP-9. In summary, these findings suggested that EA preconditioning and postconditioning could alleviate spinal cord I/R injury, which was partly mediated by autophagy upregulation-induced inhibition of apoptosis and neuroinflammation.

Cell therapy for spinal cord injury informed by electromagnetic waves

Spinal cord injury devastates the CNS, besetting patients with symptoms including but not limited to: paralysis, autonomic nervous dysfunction, pain disorders and depression. Despite the identification of several molecular and genetic factors, a reliable regenerative therapy has yet to be produced for this terminal disease. Perhaps the missing piece of this puzzle will be discovered within endogenous electrotactic cellular behaviors. Neurons and stem cells both show mediated responses (growth rate, migration, differentiation) to electromagnetic waves, including direct current electric fields. This review analyzes the pathophysiology of spinal cord injury, the rationale for regenerative cell therapy and the evidence for directing cell therapy via electromagnetic waves shown by in vitro experiments.

Current epidemiological profile and features of traumatic spinal cord injury in Heilongjiang province, Northeast China: implications for monitoring and control

STUDY DESIGN

A retrospective hospital-based study.

OBJECTIVES

Traumatic spinal cord injury (TSCI) is considered to be an important public health problem worldwide. Only a few studies concerning the regional epidemiological characteristics of TSCI have been published in China. The purpose is to evaluate the epidemiological characteristics of TSCI in Heilongjiang province in northeast China.

SETTING

The Second Affiliated Hospital of Harbin Medical University and the Fifth Hospital of Harbin City, Heilongjiang province.

METHODS

Information of 232 patients who suffered from TSCI was gathered from their charts between January 2009 and December 2013. Information on sociodemographic variables was collected from each chart, including the patient's age, sex, occupation, injury time, causes and extent of injury.

RESULTS

The average age of patients with TSCI was 45.35±14.35 years. The male/female ratio was 4:1. The incidence of TSCI increased gradually with age and peaked in the 46- to 60-year-old age category. The most common occupation was farm laborer (35.34%). Motor vehicle collisions, followed by falls, were found to be the leading cause of TSCI. Furthermore, the majority of TSCI patients (76.29%) suffered a cervical injury.

CONCLUSION

The present study reveals that TSCI is an issue in the province, and it should not be ignored. Our results provide preliminary evidence and theoretical basis for developing an integrated control program for TSCI.

Electroacupuncture at Zusanli (ST36) ameliorates colonic neuronal nitric oxide synthase upregulation in rats with neurogenic bowel dysfunction following spinal cord injury

Study designExperimental study.ObjectiveTo determine the effects of electroacupuncture (EA) at Zusanli (ST36) on colonic motility and neuronal nitric oxide synthase (nNOS) expression in rats with neurogenic bowel dysfunction (NBD) after spinal cord injury (SCI).SettingSecond School of Clinical Medical, Nanjing University of Chinese Medicine, Jiangsu, China.MethodsWe divided 30 adult Sprague-Dawley rats into a sham group (10 rats), a model group (SCI alone, 10 rats) and a EA group (SCI+EA at ST36, 10 rats). Defecation time was recorded as the time from activated carbon administration (on day 15) to evacuation of the first black stool. Immunohistochemical, real-time PCR and western blot analyses were performed to assess changes in nNOS-immunoreactive cells, and nNOS messenger RNA (mRNA) and protein, respectively, after 14 experimental days.ResultsDefecation time was lower in the EA group than in the model group (P<0.01). On immunohistochemical analysis, nNOS was localized in the myenteric plexus of the colon. The number of nNOS-immunoreactive cells and the intensity of nNOS staining were greater in the model group than in the sham group and lesser in the EA group than in the model group. Consistent with the immunohistochemical findings, nNOS mRNA and protein expression was higher in the model group than in the sham group and lower in the EA group than in the model group (P<0.05 for both).ConclusionIncreased colonic nNOS expression can induce/aggravate NBD in SCI rats. EA at ST36 ameliorated NBD, possibly by downregulating colonic nNOS expression.

Effect of Acupuncture on the Motor and Nonmotor Symptoms in Parkinson's Disease--A Review of Clinical Studies

Parkinson's disease is a neurodegenerative disorder. Parkinson's clinical feature is characterized by its motor manifestations, although its many nonmotor symptoms occur earlier and have more profound impact on the quality of patient's life. Acupuncture has been increasingly popular and has been used to treat patients with Parkinson's. In this article, we have studied the clinical reports of acupuncture treatment for Parkinson's, which were listed in Medline, PubMed, EMBASE, CNKI, and CINAHL databases in the past 15 years. It was found that acupuncture either manual or electroacupuncture stimulation at specific acupoints relieved some motor symptoms in patients with Parkinson's and markedly improved many nonmotor symptoms such as psychiatric disorders, sleep problems, and gastrointestinal symptoms. When it was used as an adjunct for levodopa, acupuncture improved therapeutic efficacy and reduced dosage and the occurrence of side effects of levodopa. However, the results were constrained by small sample sizes, methodological flaws, and blinding methods of studies. Although the evidence for the effectiveness of acupuncture for treating Parkinson's is inconclusive, therapeutic potential of acupuncture seems quite promising. More studies, either comparative effectiveness research or high-quality placebo-controlled clinical studies are warranted.

Effects of Governor Vessel electroacupuncture on the systematic expressions of NTFs in spinal cord transected rats

This study evaluated the effects Governor Vessel electroacupuncture (GVEA) on the systematic regulation of neurotrophic factors (NTFs) in the spinal segments caudal (CSS) to the site of transection in rats subjected to spinal cord transection (SCT). Using RT-PCR, we amazingly found the gene expressions of NGF, IGF-1, FGF-2, CNTF, PDGF, TGF-β1, TrkA, TrkB and TrkC were downregulated following GVEA treatment. However, the number of GAP-43 and Synaptophysin profiles in the CSS in the GVEA rats showed a significant increase, compared with non-EA animals, although both the 5-HT and corticospinal fibers have no statistical differences in the CSS. Simultaneously, there was significant recovery in hindlimb locomotor and sensory functions after GVEA treatment. Therefore, these findings challenge the past view that GVEA promotes functional restoration, which is linking to the up-regulation of NTFs in rats subjected to SCT. The present findings may give some novel indication on the mechanism of acupuncture for the treatment of SCI.

Acupuncture for preventing complications after radical hysterectomy: a randomized controlled clinical trial

We aimed to investigate the preventive effects of acupuncture for complications after radical hysterectomy. A single-center randomized controlled single-blinded trial was performed in a western-style hospital in China. One hundred and twenty patients after radical hysterectomy were randomly allocated to two groups and started acupuncture from sixth postoperative day for five consecutive days. Sanyinjiao (SP6), Shuidao (ST28), and Epangxian III (MS4) were selected with electrical stimulation and Zusanli (ST36) without electrical stimulation for thirty minutes in treatment group. Binao (LI14) was selected as sham acupuncture point without any stimulation in control group. The main outcome measures were bladder function and prevalence of postoperative complications. Compared with control group, treatment group reported significantly improved bladder function in terms of maximal cystometric capacity, first voiding desire, maximal flow rate, residual urine, and bladder compliance, and decreased bladder sensory loss, incontinence, and urinary retention on fifteenth and thirtieth postoperative days. Treatment group showed significant advantage in reduction of urinary tract infection on thirtieth postoperative day. But no significant difference between groups was observed for lymphocyst formation. By improving postoperative bladder function, early intervention of acupuncture may provide a valuable alternative method to prevent bladder dysfunctional disorders and urinary tract infection after radical hysterectomy.