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ORIGINAL ARTICLE
Year : 2006  |  Volume : 22  |  Issue : 2  |  Page : 135-138
 

Does the type of steinstrasse predict the outcome of expectant therapy?


Departments of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Anil Mandhani
Department of Urology and Renal Transplant, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.26569

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   Abstract 

OBJECTIVES: To determine the outcome of expectant therapy in steinstrasse according to its type.
MATERIALS AND METHODS: A chart review was performed on patients who underwent extracorporeal shock wave lithotripsy (SWL) between 1995 and June 2004. Demographic profile, stone size, site, characteristics of steinstrasse (type 1; multiple small fragments, type 2; lead fragment of 5 mm or more with small fragments proximal to it and type 3; multiple fragments of 5 mm or more) and mode of treatment used, were noted. Patients of steinstrasse, diagnosed on X-Ray KUB were kept on expectant treatment for 4 weeks. Patients with high grade fever and infected hydronephrosis were treated with percutaneous nephrostomy (PCN) insertion. Non responders at 4 weeks, were treated with SWL and/or ureterorenoscopy (URS). RESULTS: 1000 patients of mean age 37.85 years, with urinary stones, received SWL (827 renal stones and 173 ureteric stones). Sixty patients (6%) developed steinstrasse. Mean stone size was 2.03 cm (0.6-4 cm). Type 1, 2 and 3 steinstrasse was present in 32 (53%), 20 (33%) and 8 (13%) patients, respectively. Conservative management was successful in 30 (50%) patients at 4 weeks. 3 patients who presented with infected hydronephrosis, required PCN. The remaining (27 patients) were subjected to repeat SWL. 24 of these 27 patients could be successfully treated with SWL, whereas the remaining 3 required URS. Of non- responders to conservative treatment i.e., 30 patients, 17 (56%) and 8 (26%) patients had type 2 and 3 steinstrasse respectively, whereas only 3 out of 30 (10%) responders had type 2 and none of the responders had type 3 steinstrasse, P value < 0.01. CONCLUSION: Type 2 and 3 steinstrasse have 90% (25 out of 28 failed) chance of not responding to the conservative treatment at 4 weeks. To avoid the risk of infected hydronephrosis (5%), active intervention should be done in patients with lead fragment of 5 mm or more (type 2 and 3 steinstrasse), as early as possible. SWL is successful in most of these patients and should be the primary modality of treatment.


Keywords: Classification, extracorporeal shock wave lithotripsy, management; steinstrasse


How to cite this article:
Goyal R, Dubey D, Khurana N, Mandhani A, Ansari M S, Srivastava A, Kapoor R, Kumar A. Does the type of steinstrasse predict the outcome of expectant therapy?. Indian J Urol 2006;22:135-8

How to cite this URL:
Goyal R, Dubey D, Khurana N, Mandhani A, Ansari M S, Srivastava A, Kapoor R, Kumar A. Does the type of steinstrasse predict the outcome of expectant therapy?. Indian J Urol [serial online] 2006 [cited 2019 Aug 21];22:135-8. Available from: http://www.indianjurol.com/text.asp?2006/22/2/135/26569


Steinstrasse is a well-recognized complication of SWL.[1] Several factors are responsible for steinstrasse formation, including stone size, site, composition and power used for disintegration.[2],[3],[4],[5] It is usually transient and asymptomatic. However, steinstrasse may become static and cause partial or complete obstruction.[6] These patients present with loin pain, obstruction or infection. A sizable number of patients respond to conservative treatment, while non-responders require active intervention in form of repeat SWL, URS and PCN. We present our experience with the management of steinstrasse after extracorporeal shock wave lithotripsy (SWL) and its outcome to expectant therapy according to its type.


   Materials and Methods Top


1000 patients were subjected to SWL for urinary stones form January 1995 to June 2004. Renal stones were encountered in 827 patients and ureteric stones in 173. All patients were treated with Dornier Compact S lithotripter, as outpatients. Pre-procedural evaluation included urine culture, renal functions and intravenous urogram (IVU). Intravenous sedation was used for adults, whereas children below 14 years (27 patients) were treated under general anesthesia. Sixty patients (6%) developed steinstrasse. The mean age was 37.85 ± 9.93 years (range 8-65), 48 being males and 12 were females, including one child. After initial SWL, all patients received antibiotics and analgesics for 3-5 days. They were instructed to filter the urine and were followed fortnightly for 3 months with X-ray KUB or were asked to report in between if symptomatic.

Patients who developed steinstrasse in follow-up were included in this study and were grouped into 3 groups according to the type of steinstrasse formed.[1] Steinstrasse has been divided into 3 types: type 1; multiple small fragments, type 2; lead fragment of 5 mm or more with small fragments proximal to it and type 3; multiple fragments of 5 mm or more.[1] These were given night dose suppressive antibiotic and as per the departmental policy, were called weekly with X- ray KUB till 4 weeks of expectant therapy. In between, if patients presented with infected hydronephrosis, percutaneous nephrostomy was placed. Patients who failed to pass the fragments spontaneously during this 4 week conservative period, were treated with SWL. Power of disintegration was kept at 4-5 KV and shock waves were given at a frequency of 60-90 shocks per minute. 2 sessions of SWL were given. SWL was aimed at disintegration of the lead fragment and mechanically loosening the small fragments above it. Fluoroscopic localization of stones was done in all patients. Those having residual fragments after 2 sessions of shock wave lithotripsy, were treated with ureterorenoscopic (URS) disintegration.

SPSS-10 software was used, statistical analysis was done using non- parametric Mann Whitney test and a P value of less than 0.05 was considered as significant.


   Results Top


Sixty patients (59 adults, 1 child) developed steinstrasse with a mean age of 37.85 years and mean stone size of 2.03 cm (0.6-4 cm). The incidence of steinstrasse increased with stone size [Table - 1]. In 5 patients with stone size greater than 3 cm who developed steinstrasse, three had a stent in situ before lithotripsy. Incidence of steinstrasse also varied with the location of the stone in the pelvicalyceal system [Table - 2]. The most common site of steinstrasse was the distal one- third of the ureter in 32 patients (53%), followed by the upper one-third in 20 (33%). Radiologically, 32 (53.3%) patients had type 1 [Figure - 1], 20 (33.3%) patients type 2 [Figure - 2] and 8 (13.3%) patients had type 3 [Figure - 3] steinstrasse. The length of the ureter containing steinstrasse varied from 1 cm to 9 cm. Most of the symptomatic patients presented with flank pain, while others had nausea, vomiting, fever and bladder irritation. Twelve (20%) patients were asymptomatic. Expectant treatment was successful in 30 (50%) patients. Percutaneous nephrostomy was needed in 3 (5%) patients who presented with pain and fever. Of these 3 patients, 2 passed their stones spontaneously, while one patient required ureteroscopy for stone removal, once the infection was controlled. The remaining 27 patients who did not respond to expectant therapy, were treated successfully with SWL. 3 (11%) patients who failed SWL, required ureteroscopic stone removal. 3 out of 30 (10%) patients who responded to expectant therapy and 25 out of 30 (83%) who did not respond to expectant therapy, had type 2 and type 3 steinstrasse ( P value<0.01) [Table - 3]. Overall, conservative management for 4 weeks was successful in 27 of 32 patients (84.3%) of patients with type 1 steinstrasse and in 3 of 28 (10.7%) patients with type 2 and 3 steinstrasse. None of the patients required open ureterolithotomy.


   Discussion Top


Incidence of steinstrasse has decreased with time, as earlier series have reported the incidence as high as 20%.[7] Due to refinement in the technique and proper case selection, it has decreased to 6%, that equals the incidence in the present study.[5]

Incidence of steinstrasse increases with stone size.[2],[3],[4],[5] In the present series as well, when the stone size was above 2 cm, the incidence rose to 10-12%, while it was only 0.6% with stone size below 1 cm.

Site of the stone in the pelvicalyceal system also seems to contribute for the formation of steinstrasse, as the stone situated in the renal pelvis and superior calyx are likely to fall more promptly in the ureter along with a leading fragment.[8] This instantaneous fall of the stone fragment from the superior calyx and renal pelvis may be on account of a relatively straighter path of the exiting stones from these areas, thus dropping easily in the upper ureter. More than half of our patients had stone either in renal pelvis or superior calyx. Similar observations have been made in other studies.[9],[10]

Larger stones are supposed to produce larger fragments if treated at higher KV, so the primary aim should be to pulverize the stone than to fragment it.[8],[11]

The most common site of steinstrasse was distal ureter (53%), followed by proximal (33%) and mid-ureter (14%). This distribution may be the result of narrowing at the uretero-vesical junction, which causes the fragments to accumulate above it. Other causes may be presence of stenosis at the ureteric orifice or any narrowing caused by subtle stricture as result of previous surgery or infection.[11]

Conservative management of type I steinstrasse was effective in 84.3% cases, whereas a large number of our patients with type 2, 3 steinstrasse, required repeat SWL. We treated patients with SWL, if they did not pass stones within four weeks. There is no consensus in the literature, at what time interval after SWL, a lead fragment should be treated. We thought that an interval of 4 weeks after steinstrasse- formation would be sufficient enough for expectant treatment, to avoid the risk of infected hydronephrosis, as 5% of our patients (3/60) developed infected hydronephrosis within 4 weeks.

Modalities for treating steinstrasse causing obstruction or infection vary in literature, with percutaneous nephrostomy being used as the initial procedure in almost all cases in one series.[1] We thought that nephrostomy should not be put in all cases and only symptomatic patients with evidence of infection should be treated with PCN, as it is an invasive procedure with known complications. Three patients who presented with high-grade fever and infected hydronephrosis, were initially managed by insertion of percutaneous nephrostomy (PCN). Placement of PCN in such situations is advantageous as it rapidly decompresses the system, thus relieving acute pain and plummeting fever, besides facilitating the spontaneous passage of the stone.[12]

We found repeat SWL as the most useful modality for treating patients who failed expectant therapy. Repeat SWL was primarily aimed at disintegrating the lead fragment causing obstruction and mechanically loosening the small fragments proximal to it.

Ureteroscopic manipulation was indicated in afebrile patients after repeat SWL failure (2 sessions) or if the steinstrasse did not resolve over a period of two weeks, even after placing PCN. Ureteroscopy is challenging in these patients and one should anticipate problems like failure to pass a guide wire across the stone and chances of ureteric perforation.[13] As the ureter above the obstruction is dilated, irrigation used, may wash the fragments back into the kidney (usually in the lower calyx) from where the clearance may be difficult and may require additional treatments.

Placing a ureteric stent before SWL does not prevent steinstrasse, but prevents its complications.[14],[15] Prophylactic stenting should be used in patients with large stone burdens (>2-2.5 cm), solitary functioning kidneys, long-standing hydronephrosis, struvite stone or with known urinary infection prior to treatment.[16] We used stent only in patients with stones greater than 3 cm in size or those having post PCNL residue.

Lastly we recommend a simple algorithm to treat the patients with steinstrasse [Figure - 4].


   Conclusion Top


Most of the patients with steinstrasse, with lead fragment lesser than 5 mm can be managed conservatively. PCN should be done when there is obstruction, infection or renal damage. SWL should be given as early as possible for type 2 and 3 steinstrasse, as there is only 11% chance of success to expectant treatment at 4 weeks. Ureteroscopy should be reserved for non-responders to SWL.

 
   References Top

1.Coptcoat MJ, Webb DR, Kellet MJ, Fletcher MS, McNicholas TA, Dickinson IK, et al . The complications of extracorporeal shockwave lithotripsy: Management and prevention. Br J Urol 1986;58:578-80.   Back to cited text no. 1    
2.Dretler SP. Extracorporeal shockwave lithotripsy: A review of its first two years of operation in the United States. Urol Ann 1987;1:1-4.  Back to cited text no. 2    
3.Lingeman JE, Coury TA, Newman DM. Comparison of the results and morbidity of percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy. J Urol 1987;138:485-7.  Back to cited text no. 3    
4.Dretler SP. Stone fragility-A new therapeutic distinction. J Urol 1988;139:1124-6.  Back to cited text no. 4  [PUBMED]  
5.Kim SC, Oh CH, Moon YT, Kim KD. Treatment of steinstrasse with repeat extracorporeal shock wave lithotripsy: Experience with piezoelectric lithotripter. J Urol 1991;145:489-91.  Back to cited text no. 5  [PUBMED]  
6.Coptcoat MJ, Webb DR, Kellet MJ, Whitfield HN, Wickham JE. The steinstrasse: A legacy of extracorporeal lithotripsy? Eur Urol 1988;14:93-5.  Back to cited text no. 6  [PUBMED]  
7.Fedullo LM, Pollack HM, Banner MP, Amendola MA, Van Arssalen KN. The development of steinstrasse after ESWL. Frequency, natural history and radiologic management. AM J Roentgenol 1988;151:1145-7.  Back to cited text no. 7    
8.Madbouly K, Sheir KZ, Elsobky E, Eraky I, Kenawy M. Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: A statistical model. J Urol 2002;167:1239-42.  Back to cited text no. 8  [PUBMED]  
9.Soyupek S, Armagan A, Kosar A, Serel TA, Hoscan MB, Perk H, et al . Risk factors for the formation of steinstrasse after shockwave lithotripsy. Urol Int 2005;74:323-5.  Back to cited text no. 9    
10.Abdel KM, Sheir KZ, Mokhtar AA, Eraky I, Kenawy M, Bazeed M. Predicting of success rate after extracorporeal shock wave lithotripsy of renal stones- A multivariate analysis model. Scand J Nephrol 2004;38:161-7.  Back to cited text no. 10    
11.Roth RA, Beckmann CF. Complications of extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy. Urol Clin North Am 1988;15:155-7.  Back to cited text no. 11  [PUBMED]  
12.Sayed MA, El-thar AM, Abdul-ella HA, Shaker SE. Steinstrasse after extracorporeal shock wave lithotripsy: Etiology, prevention and management. BJU Int 2001;88:675-8.  Back to cited text no. 12    
13.Sigman M, Laudone V, Jerkins AD. Ureteral meatotomy as a treatment of steinstrasse following extracorporeal shock wave lithotripsy. J Endourol 1988;2:41-3.  Back to cited text no. 13    
14.Kirkali Z, Esen A, Akan G. Place of double-J stents in extracorporeal shock wave lithotripsy. Eur Urol 1993;23:460-2.  Back to cited text no. 14    
15.Sulaiman MN, Buchholk NP, Clark PB. The role of ureteral stent placement in the prevention of steinstrasse. J Endourol 1999;13:151-5.  Back to cited text no. 15    
16.Riehle RA. Selective use of ureteral stents before extracorporeal shock- wave lithotripsy. Urol Clin North Am 1988;15:499-506.  Back to cited text no. 16    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]

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