Discussion
postoperative pain, ureter damage, pain, wall injury, postoperative ureteral injury, sepsis
EROSION, INFLAMMATORY RESPONSES, CONTRACTIONS, URETER, ADVERSE EFFECTS, DILATION, SEPSIS
Studies have provided evidence that alpha-blocker medications are safe and effective for both children and adults. Specifically, silodosin consistently demonstrates higher rates of stone expulsion, lower occurrence of adverse effects, reduced pain and decreased reliance on analgesics compared to calcium channel blockers, other adrenergic alpha-antagonists or placebo [Whenever possible, MET should be employed. However, it should be noted that spontaneous passage of the stone may not always be feasible, and surgical intervention may be required based on factors such as stone size, position and symptom progression. Specifically, stones larger than 5 mm or those located higher in the ureter are less likely to pass naturally. If the ureteroscope cannot pass through the ureter, there is a surgical risk, which may necessitate the placement of a stent and a subsequent operation once the ureter has adequately dilated [In our study, we proposed the hypothesis that silodosin could potentially prevent significant ureteral wall injury associated with UAS insertion. To our knowledge, there is a lack of studies demonstrating the effectiveness of silodosin in reducing ureteral wall injury during UAS insertion.According to the explanation, silodosin has the potential to be more effective than other alpha-blockers in dilating the ureter [Within our study, we observed that out of the patients in group A, 23 (33.3%) experienced ureteral wall injury following UAS insertion, while in group B, this occurred in 40 patients (59.7%). The presence of significant wall injury, classified as grade 2 or higher and involving an area above the smooth muscle layer, was detected in 6 patients (8.7%) in group A and in 26 patients (38.8%) in group B. There was a statistically significant difference in the grade of ureteral wall injury between the two groups (Our findings revealed that silodosin reduced the intensity of postoperative pain in the early stages and also decreased the duration of surgery. We propose that by blocking α-adrenergic receptors, silodosin diminishes the strength of ureteral contractions and the frequency of ureteral peristalsis, resulting in a more relaxed and less active ureter. This relaxation allows for the utilization of a reinforced UAS, which, in turn, can generate significant shear stress, potentially leading to various levels of damage to the ureteral wall, ranging from mucosal erosion to ureteral avulsion [Moreover, the interaction between the UAS and the mucosal layer triggers nociceptors, leading to rapid inflammatory responses and subsequent postoperative discomfort [Therefore, silodosin, a super selective a1A antagonist, may be significantly more effective in preventing ureter damage during UAS implantation [This finding aligns with the results of Kim et al., who conducted a study involving 44 patients in the control group and 43 patients in the silodosin group. Their research demonstrated that prevention of significant postoperative ureteral injury that involved the smooth muscle layer was more successful with silodosin than in the control group (9.3 vs. 27.3%; In a recent study conducted on an adult population, a higher concentration of alpha-adrenergic receptors in the distal ureter was utilized to facilitate the dilation of this segment of the ureter through the use of tamsulosin. The researchers postulated that administering -1A receptor agonists before surgery would decrease the failure rate of UAS passage during URS for stone removal. Patients who received tamsulosin treatment for at least 1 week before the procedure exhibited significantly higher success rates in the first attempt of UAS passage compared to those who did not receive any preoperative treatment (87% vs. 43%). This led to a reduction in the number of anesthesia exposures for patients and decreased operative time and costs for healthcare providers [In patients with RIRS, ureteral stents are also linked to lower urinary tract symptoms, flank discomfort, postoperative sepsis and poor cost-effectiveness [In Kim et al.’s [Our study had certain limitations, as it was conducted at a single center. Additionally, due to the subjective and multidimensional nature of the postoperative pain, the VAS score may not fully capture the complete pain experience. However, clinical decision making relied on the pain scale, which indicates the active efforts made by clinicians to manage and control pain.Further randomized double-blind multicenter larger studies from other institutions for further confirmation of the efficacy of preoperative administration of silodosin therapy with long-term follow-up would be necessary soon.