Re: “Comparison of dual-agent alpha-blocker treatment with single agent in management of refractory lower urinary tract symptoms” by Ranjan et al

Dear Editor, I read with great interest the article by Ranjan et al1 entitled “Comparison of dual-agent alpha-blocker treatment with single agent in management of refractory lower urinary tract symptoms,” which investigates the efficacy and safety of dual alpha-blocker therapy in patients with refractory lower urinary tract symptoms (LUTS). While the study presents significant data, I would like to underscore several points that may warrant further discussion or clarification. Upon review of the literature, response rates to silodosin in men with LUTS and benign prostatic hyperplasia typically range from 65% to 74%2,3. However, in the present study, only 78 out of 250 patients responded to the initial silodosin treatment, notably lower than reported rates. The authors did not provide a sufficient explanation for this difference in the discussion section. This lower responder ratio raises the question of whether patients with potential underlying urethral stricture or bladder neck contracture were included in the study cohort. Were such anatomical etiologies evaluated or excluded through diagnostic procedures such as cystoscopy or retrograde urethrography? A diminished response to silodosin could potentially be attributed to these factors. Furthermore, the authors assessed only the total International Prostate Symptom Score. However, as is well-established, the International Prostate Symptom Score can be subdivided into storage and voiding subscores. This distinction is crucial, as it may aid in identifying patients who could benefit from combination therapy with an anticholinergic agent in addition to an alpha-blocker. Several studies have demonstrated that alpha-blocker plus anticholinergic combination therapy provides significantly greater symptomatic relief and improvement in quality of life in patients with moderate to severe LUTS compared with alpha-blocker monotherapy4,5. It would be valuable to ascertain which subscore (voiding versus storage) exhibited more improvement in the dual therapy group. Incorporating this consideration into the limitations section would enhance the depth of the discussion. Moreover, the study does not present any data about nocturia. It would be of interest to determine whether there was a statistically significant difference in the frequency of nocturia episodes before and after treatment and whether a difference existed between the treatment groups in this regard. Finally, the authors combined silodosin with alfuzosin but did not clearly justify the rationale for selecting this specific combination over other agents such as tamsulosin, doxazosin, or a 5-alpha-reductase inhibitor in dual therapy. A more detailed discussion on the reasoning behind the choice of alfuzosin for combination therapy would support the clinical relevance of the study. I believe that addressing these points would further clarify the study’s findings and contribute to the growing literature on LUTS and benign prostatic hyperplasia management.