|Year : 2003 | Volume
| Issue : 1 | Page : 46-49
The steinstrasse : A legacy of extracorporeal lithotripsy
Mufti Mahmood, Arif Hamid, Vipul Tandon, US Dwivedi, Harbans Singh, PB Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
P B Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: To determine the causes of steinstrasse and to assess the success of primary ureteroscopic removal using pneumatic lithotripsy.
Methods: Three hundred and two patients with urinary stones (242 renal and 60 ureteric) underwent extracorporeal shock wave lithotripsy treatment using Stonelith electrohydraulic lithotripter from June 1999 to July 2002 in the Department of Urology, Institute of Medical Sciences, Banaras Hindu University. Of these, 29(9.6%) developed steinstrasse. There were 23 males and 6 females in the age group of 24-66 years. After ESWL the patients were followed weekly using plain films and ultrasonography for the 1 st month and thereafter monthly for 2 months. Their radiological appearance was classified into 3 types. Majority of the patients developing steinstrasse had a stone size of 2-3 cm and most of the steinstrasse was found in the lower ureter usually after 6001-9000 shocks at a mean power of >16 kv. The length of the steinstrasse was 3-4 cm in the majority of patients.
Results: Conservative management was successful in 15 patients (51.7%); repeated ESWL in 4 (13.8%). Ureteroscopic removal using pneumatic lithotripsy under i/v sedation was successful in 10(34.5%) patients.
Conclusions: Large stone burden (>2 cm) and use of high energies (>16 kv) are leading factors responsible for the development of steinstrasse. Ureteroscopic removal using pneumatic lithotripsy is a definitive and predictable treatment modality with a high success rate.
Keywords: Renal stones, ESWL, steinstrasse, ureteroscopy.
|How to cite this article:|
Mahmood M, Hamid A, Tandon V, Dwivedi U S, Singh H, Singh P B. The steinstrasse : A legacy of extracorporeal lithotripsy. Indian J Urol 2003;20:46-9
|How to cite this URL:|
Mahmood M, Hamid A, Tandon V, Dwivedi U S, Singh H, Singh P B. The steinstrasse : A legacy of extracorporeal lithotripsy. Indian J Urol [serial online] 2003 [cited 2019 Aug 19];20:46-9. Available from: http://www.indianjurol.com/text.asp?2003/20/1/46/37124
| Introduction|| |
A steinstrasse (or stone street) is an aggregation of particles in the ureter seen on plain X-ray after extracorporeal shockwave lithotripsy (ESWL). It is a recognized complication of ESWL.  It is a common radiological finding on routine radiographs taken between 24 and 48 hours after lithotropsy (15%) but they are usually transient and asymptomatic.  The steinstrasse, however, may become static and cause partial or complete obstruction, often superimposed with infection. A solitary kidney is especially at risk. We present our experience with steinstrasse after ESWL and assess the various treatment modalities used to resolve the problem.
| Patients and Methods|| |
Three hundred and two patients with urinary stones (242 renal and 60 ureteric) were treated by extracorporeal shock wave lithotropsy (ESWL) from June 1999 to July 2002. Of these, 29 (9.6%) developed steinstrasse (age range 24-66 years); 23 were men (7.6% of all patients treated). After ESWL, the patients were followed weekly using plain films and ultrasonography for the 1 11 month and thereafter monthly for 2 months. The aim was to monitor stone disintegration and symptoms, and to detect any complications. Steinstrasse developed after first ESWL session or after several sessions. As per their radiological appearance the steinstrasse was classified in to 3 types viz: Type I (made up of particles 2 mm in diameter or less), Type II (a leading large fragment of 4-5 mm in diameter with a tail > 2 mm particles), and Type III (composed of large fragments).
The various types of management procedures chosen were conservative, repeated ESWL and ureteroscopy using pneumatic lithotropsy as per the selection criteria mentioned in [Table - 1].
Conservative management of steinstrasse included a meticulous follow-up for 3-4 weeks, antibiotics and analgesics. Repeated ESWL was aimed at disintegrating the leading fragment and at mechanically loosening the small fragments above it. Good targeting using fluoroscopic localization with the patients in supine/prone position is essential for ESWL. Ureteroscopy was done with 8.5 F rigid ureteroscope (Wolf) using pneumatic lithotripsy (Swiss lithoclast). Ureteroscopy was done in the operating room as an outpatient procedure under iv sedation.
| Results|| |
The steinstrasse developed 1 day to 3 months after stone fragmentation in 29 (9.6%) of 302 patients treated by ESWL. The most common symptom of steinstrasse was flank pain, while 10% of patients were asymptomatic. The incidence of steinstrasse increased with stone size. Of 100 patients with stones <1 cm, only 2 (2%) developed steinstrasse, whereas 14 (11.2%) of 125 with stones 1-2 cm and 13 (16.8%) of 77 with stones of 2-3 cm developed steinstrasse.
In the majority of patients (17%) the steinstrasse developed after 6001-9000 shocks [Table - 2]. The incidence of steinstrasse increased after using high energies mean of 19 kv at the start of the treatment [Table - 2]. The most common location for steinstrasse was the lower ureter (93.3% in the right lower ureter and 86.6% in the left lower ureter) [Table - 3]. Radiologically, steinstrasse was classified into 3 types, according to the classification of Coptcoat et al  Fourteen patients (48.27%) had type I, 12(41.37%) type II, and 3 (10.34%) type III steinstrasse [Table - 3]. The length of ureter containing steinstrasse is also shown in [Table - 3]. Of the 29 patients, 24(82.75%) were treated conservatively. In 3(10.3%) patients repeated ESWL and in 2(6.8%) patients ureterolithotripsy was used as a primary procedure. The overall results of our management are summarized in [Table - 4].
| Discussion|| |
In early studies of ESWL, steinstrasse was common, occurring in upto 20% of patients in the series of Fedullo et al.  After refining the technique the incidence of steinstrasse decreased and was 6% in the series of Kim et al  and 9.6% in the present series. The presentation of patients with steinstrasse is variable. In the present series, 34.48% of 29 patients were asymptomatic whereas 51.72% had classic renal colic, 3.44% had nausea and vomiting while bladder irritation occurred in 10.34%. Weinerth et al  noted that 26% of 19 patients with steinstrasse were asymptomatic, whereas 42% had renal colic and 26% had nausea with or without vomiting. Overall, the development of steinstrasse correlated directly with stone burden. ,, Among ESWL patients, Kim et al  observed a 0.3% incidence of steinstrasse for stones <1 cm compared with 18.8% for stones >4 cm. In the present series, the incidence of steinstrasse for stones <1 cm was 2% while it was 11.2% for stones 1-2 cm and 16.8% for stones 2-3 cm in size. We also found that high energies (mean >16 kv) during the initial treatment caused increased incidence of steinstrasse. Some patients (20.45%) had steinstrasse formation at a mean power of 19 kv, whereas the incidence increased to 50% at a mean power of 21 kv. This was found to be irrespective of the stone size as majority of such patients has a stone size that ranged from <1 to 2 cm. The incidence of steinstrasse was maximum (17%) in those patients receiving 6001-9000 shocks as compared to 3.3-4.5% in all other groups. This can probably be explained due to the large sample size in this subgroup. The most common location for steinstrasse was the lower ureter (87% to 93.3%) which may be a result of the narrowing at the vesico-ureteric junction, leading to the accumulation of fragments above it or sometimes to ureteric/meatal stenosis. Similar distribution was reported by Kim et al.  (60% distal) and Fedullo et al  (75% distal). Radiographically, steinstrasse was categorized into 3 types as classified by Coptcoat et al.  Type I (made up of particles 2 mm in diameter) were the commonest, i.e.. 14 patients (48.27%) followed by Type II (a tail of 2 mm particles with a large leading fragment of 4.5 mm in diameter) in 12 patients (41.37%), and Type III (composed of large particles) in 3 patients (10.34%). Similar distribution of the various types of steinstrasse was reported by Coptcoat et al.  In their series of 32 patients. 17 patients (54%) had Type I, 11 cases (34%) Type II, and 4 cases (12%) Type III. The highest incidence of Type I streinstrasse in the present series indicated that our policy of pulverizing the stones rather than fragmenting them was largely successful. Type lI steinstrasse are created when a large fragment falls down into the ureter early during treatment because of poor focusing on the pelvic stone mass. It is probable that a Type II steinstrasse results from an inadequate number of shocks for that particular stone mass. 
The conservative management of uncomplicated steinstrasse was effective in 51.7% patients in the present series. Similar results were reported by Kim et al.  The conservative treatment was given for a period of 3-4 weeks. A number of studies have shown that majority of asymptomatic patients with steinstrasse clear their fragments spontaneously over 2-4 weeks ,, . Failure of steinstrasse to resolve within 3-4 weeks may necessitate intervention.  Repeated ESWL was given to 5(17.2%) patients and it was successful in 4(13.8%). In the series of Kim et al  repeated ESWL was successful in 23% patients with ESWL used to disintegrate the leading fragment in some and in others to mechanically loosen them. Ureteroscopic manipulation using pneumatic lithotripsy was indicated in afebrile patients after the failure of either repeated ES WL or conservative treatment. Ureteroscopic removal was done either as a primary or as an auxilliary procedure in 10 (34.48%) patients. It was successful in the 1st sitting in 9 (31.03%) whereas 2nd sitting was required in 1(3.4%) for clearing the fragments. Weinerth et al  reviewed 19 patients with steinstrasse, among whom 37% had resolution of their steinstrasse with observation alone. Ten patients (52%) ultimately required ureteroscopic manipulation. Our results with pneumatic lithotripsy have been encouraging with all the 10 patients (100%) successfully clearing the fragments without any complication. A number of authors have reported on successful use of the lithoclast for stones throughout the urinary tract. ,, Holbauer et al  compared the efficiency and safety of electrohydraulic lithotripsy with pneumatic lithotripsy and found equivalent efficacy but significantly greater safety with pneumatic lithotripsy.
In the present series the length of ureter affected by steinstrasse appeared to have no effect on success of treatment.
| Conclusions|| |
- Various factors leading to steinstrasse are:
1. Stone size of >2 cm.
2. Use of high energies >16 kv (irrespective of stone size) leading to formation of larger fragments.
- Ureteroscopic removal using pneumatic lithotripsy is an efficient, definitive and predictable treatment modality with a success rate approaching 100%.
| References|| |
|1.||Coptcoat ML Webb DR, Kellet ME Whitfield HN, Wickham JEA. Complication of ESWL : Management and prevention. Br J Urol 1986; 58: 578-580. |
|2.||Coptcoat MJ. Webb DR. Kellet MJ. Whitfield HN, Wickham JEA. The steinstrasse : A legacy of ESWL. Eur Urol 1988; 14: 93-95. |
|3.||Fedullo LM. Pollack JM. Banner MP, Amendola MA, Van Ars Dalen KN. The development of steinstrasse after ESWL : frequency. natural history and radiologic management. Am J Roentgenol 1988: 151: 1145-1147. |
|4.||Kim SC. OH CH. Moon YE. Kim KD. Treatment of steinstrasse with repeat extracorporeal shock wave lithotripsy : experience with piezoelectric lithrotripter. J Urol 1991: 145: 489-491. |
|5.||Weinerth JL, Flatt JA, Carson CC. Lessons learned in patients with large steinstrasse. J Urol 1989: 142: 1425-1427. |
|6.||Errando Smet C, Laguma Pes P, Salvador Vayarri J et al. Endoscopic lithotripsy by means of lithoclast. Arch Esp Urol 1995: 48: 621-624. |
|7.||Leidi GL. Berti GL, Canclini L et al. Ureteroscopy and stone lithotripsy with lithoclast : Personal experience. Arch Ital Urol Androl 1997: 69: 181-183. |
|8.||Terai A, Takeuchi H, Terachi T et al. Intracorporeal lithotripsy with the Swiss lithoclast. Int J Urol 1996: 3: 184-186. |
|9.||Hofbauer J. Hobarth K, Marberger M. Electrohydraulic versus pneumatic disintegration in the treatment of ureteral stones : A randomized prospective trial. J Urol 1995: 153: 623-625. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4]