Re: Randomized Controlled Trial to Compare the Safety and Efficacy of Tamsulosin, Solifenacin, and Combination of Both in Treatment of Double-J Stent-Related Lower Urinary Symptoms

Abstract

I read the newly published article entitled "Randomized Controlled Trial to Compare the Safety and Efficacy of Tamsulosin, Solifenacin, and Combination of Both in Treatment of Double-J Stent-Related Lower Urinary Symptoms" by Shalaby and associates (1). They have concluded that combined tamsulosin and solifenacin regimen is effective to alleviate double-J stent related symptoms in comparison with both monotherapies. Ureteral stents, especially double-J stents, are associated with some discomforts and strategies implemented to attenuate those, including exact stent indications, stent insertion maneuvers, designation and administering drugs have been proposed so far (2). Given these notions, only three articles, including the mentioned study, have shown the effect of combination of adrenergic alpha-1 antagonist and anti-cholinergic on relieving ureteral stent-related symptoms (3, 4). All investigations have had some limitations based on study methods, but their findings are of great value for designing complementary investigations. Thanks to the investigators for their well-designed trial, but there are some thoughts to be mentioned. The first concern is that all procedures including ureterorenoscopy (URS)/ureterolithotomy, percutaneous nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy (ESWL) and endopyelotomy were enrolled in that study, while it could influence the results especially in the third and fourth groups of study because of including more composite of PCNL, ESWL and endopyelotomy cases compared with control group (26.25% versus 31% and 25% versus 31%, respectively). All types of surgeries might have different complications and consequently varied symptoms interfered with the effect of studied drugs. ESWL compared with ureteroscopy has lower complications consisted of flank pain and dysuria; however, stone-free rate has been shown to be more in those undergoing ureteroscopic procedures (5, 6). Moreover, PCNL in comparison with ESWL presents more stone-free status, although it is accompanied by more flank pain and major postoperative complications (7). Endopyelotomy is also associated with less pre-and post-surgical complications (8). Theses confounding factors might interfere with their conclusion; hence we cannot exactly state that their findings are attributable to either the drugs' effect or having more number of surgeries with low complications allocated in some groups. Regarding such confounding factors, it is reasonable to conduct separate analyses only for those undergone URS as a main intervention in all groups, about 70% in all groups. Since providing further analyses will be helpful to differentiate between drug-and procedure-related impacts on evaluated scores, and to make the