Treatment of steinstrasse with repeat extracorporeal shock wave lithotripsy: experience with piezoelectric lithotriptor

Extracorporeal shock wave lithotripsy versus laser lithotripsy in the treatment of post-SWL steinstrasse: a randomized comparative study

OBJECTIVE

To compare the efficacy of Holmium laser lithotripsy with that of extracorporeal shock lithotripsy (SWL) for post-SWL ureteral steinstrasse.

MATERIALS AND METHODS

From January 2022 to July 2023, 36 patients with post-SWL ureteral steinstrasse were randomly divided into laser lithotripsy and SWL groups. Patients with pain, moderate to marked hydronephrosis, large leading stone fragments, and showing no spontaneous resolution within 3-4 weeks after medical expulsive therapy were included. Patients with sepsis were excluded. The success rate was the primary outcome. We compared the perioperative data between the groups.

RESULTS

The success rate was higher in the ureteroscopy group than in the SWL group (p = 0.034). SWL was a significantly longer operation, and the fluoroscopy time was significantly longer in the SWL group than in the URS group (p = 0.027). Auxiliary procedures were more frequently performed in the SWL group than in the URS group (p = 0.02). JJ stents were inserted in 100% of patients in the URS group. Three patients (16.7%) underwent conversion to laser ureteroscopy after the second SWL session failed. No significant difference in the incidence of postoperative complications was observed between the groups, but the incidence of postoperative LUT was high in the ureteroscopy group. The mean hospital stay was 30 h in the ureteroscopy group. SWL was performed without the need for hospital admission.

CONCLUSION

Ureteroscopic laser lithotripsy for steinstrasse was safe and effective, with a higher success rate, shorter fluoroscopy time, and shorter recovery period than SWL.

Ureteral wall thickness as a predictor for non-invasive treatment success for steinstrasse. Can we save time?

PURPOSE

We aimed to define factors affecting the non-invasive overall treatment success (medical expulsive therapy (MET) ± shock wave lithotripsy (SWL)) for uncomplicated ureteral steinstrasse (SS) clearance.

METHODS

We retrospectively evaluated consecutive patients who underwent SWL for renal stones between 2017 and 2021. Patients with uncomplicated SS were included. All patient's demographic and radiological data, e.g., age, gender, pre-SWL stenting, SS site, type, leading stone size in widest diameter (< 10 mm and ≥ 10 mm), ureteral wall thickness (UWT) in mm against the leading stone were collected. If SS was diagnosed, medical treatment was given for 4 weeks. In case of MET failure, either SWL for the leading stones + MET or direct URS was done. Non-invasive treatment success (SFR) was considered if complete clearance of SS occurred with no complications or the need for invasive intervention.

RESULTS

A total of 145 patients were included with mean age of 45.9 ± 12.4 years. SFR in case of MET only occurred in 27.9%. Complications happened in 26 patients (17.9%). Non-invasive treatment SFR was achieved in 78 patients (53.8%) totally where SS type I, leading stone size ≤ 10 mm type and decreased UWT around the leading stone increased treatment success.

CONCLUSION

Ureteral wall thickness is an important factor predicting SS management success. Besides the decreased UWT, non-invasive management should be offered for type I SS with leading stone ≤ 10 mm.

A Rare Case of Spontaneous Steinstrasse

Spontaneous steinstrasse ("stone street") is a collection of stones within the ureter and is a rare and understudied event. Factors such as infection, altered kidney function, and degree of obstruction are used to define the most adequate therapeutic option. Treatment can be either conservative or surgical. The decision of which depends on the clinical presentation. This paper reports a rare case of a 59-year-old patient with spontaneous steinstrasse examined at a urology clinic. Surgical intervention was required because of altered kidney function. The patient is currently undergoing follow-up for the metabolic investigation.

Using vacuum-assisted ureteral access sheath in the treatment of complex steinstrasse

Steinstrasse is an iatrogenic condition resulting from upper urinary tract lithotripsy. Uncomplicated steinstrasse can be managed expectantly. Complex steinstrasse can pose a therapeutic challenge. The vacuum-assisted ureteral access sheath (vaUAS) is similar to a conventional ureteral access sheath but has a side branch that can be connected to vacuum apparatus. This device seemed to be useful in the management of complex steinstrasse. 35 patients with complex steinstrasse, defined as steinstrasse containing ≥ 4 stones or with an aggregate length of ≥ 1.5 cm, were treated in four tertiary medical centers using the vaUAS in this prospective and non-randomized study. The vaUAS was inserted into the ureter over a guidewire until the tip of the vaUAS was in contact with the lowermost stone fragment. A 7 Fr./8.4 Fr. semirigid ureteroscope and a holmium laser were used to pulverize the obstructing stone. All the stone fragments were aspirated either in the space between the scope and the sheath, or through the channel of the sheath by withdrawing the scope to the proximal of the aspiration port. All patients were steinstrasse-free at end of the procedure, as assessed visually and by KUB. At the 3-month follow-up, 94.3% of patients were stone-free with or without a supplementary procedure. There were no perioperative complications. Five patients experienced postoperative fever and/or significant hematuria, and one patient had transient sepsis, a grade I and IV Clavien complication, respectively. vaUAS can be an effective adjunctive device in the management of complex steinstrasse.

Spontaneous resolution of a spontaneous steinstrasse: a case report

A 63-year-old man presented with a 4-day history of right sided loin-to-groin pain. Computed tomography imaging revealed a 22 mm by 7 mm volume of contiguous ureteric calculi at the right vesicoureteric junction. Spontaneous steinstrasse was diagnosed with no recent history of extracorporeal shock wave lithotripsy (ESWL) or other urological intervention to the right kidney. Metabolic testing was negative. An initial plan was made for urgent primary ureteroscopy and lithotripsy, however, the patient spontaneously passed 20–25 calculi at home whilst awaiting his operation date. He was reviewed in clinic and his symptoms had resolved. His ureteroscopy was cancelled. This case represents an example of spontaneous steinstrasse with no identified causative factors, a rare occurrence on which little literature is available presenting a management dilemma to the treating clinician. The case described resolved prior to intervention prompting us to suggest that spontaneous steinstrasse can be initially managed conservatively, as in ESWL-associated steinstrasse.

'Stone street' ureter

We would like to submit an interesting image of ureteric steinstrasse post lithotripsy procedure resembling a cobble stone street.

Can we predict the need for intervention in steinstrasse following shock wave lithotripsy?

Introduction:

Steinstrasse (SS) is a known complication of shock wave lithotripsy (SWL). Although the majority of SS clears spontaneously, about 6% require intervention. This study was carried out to identify the factors that determine the need for intervention in SS.

Materials and Methods:

This was a retrospective study of all patients who developed steinstrasse following SWL at our center. They were divided into two groups: a) Those cleared spontaneously and b) Those required intervention. The two groups were compared with regard to demographic profile, stone factors and factors related to steinstrasse.

Results:

Out of 2436 cases of SWL, 89 (3%) formed steinstrasse. The majority of the patients (35%) who required intervention had stone sizes of 10-14 mm. Coptcoat type III steinstrasse required significantly more interventions for clearance (P = 0.001). The site and the size of the SS was not a predictor of intervention for SS.

Conclusions:

Early intervention is warranted in patients with steinstrasse where the lead fragment is >5 mm (Coptcoat type III).

Pediatric extracorporeal shock wave lithotripsy: multi-institutional results

AIM

To evaluate the efficacy, auxiliary procedures and complications of pediatric extracorporeal shock wave lithotripsy (ESWL) performed with electrohydraulic lithotripters.

METHODS

Children with urolithiasis, aged between 0 and 15, were retrospectively evaluated. ESWL was performed by using two different electrohydraulic lithotripters, Elmed Multimed Classic (Elmed Medical Systems, Ankara, Turkey) and E-1000 (EMD Medical Systems, Ankara, Turkey), between January 2008 and December 2012 in four different referral centers in Turkey.

RESULTS

85.5% of patients were stone-free at 3 months. Further ESWL treatment was needed in 33.7% of the cases (one session, n = 55; two sessions, n = 15; three sessions, n = 13). Steinstrasse occurred in 10 patients but 8 of them cleared completely during the follow-up period. Urinary tract infection was detected in 3 (3.9%), fever in 3 (3.9%) and a small subcapsular hematoma in one (1.3%) patient, respectively. When the stones were divided into two groups as those with diameters &lt;10 mm and ≥10 mm, it was found that the stone-free rate was associated with stone diameter, and that the smaller diameters had higher but statistically insignificant stone-free rates (P = 0.196).

CONCLUSION

ESWL yields favorable results with low rates of complication and auxiliary procedures in selected pediatric patients.

Predictive factors and management of steinstrasse after shock wave lithotripsy in pediatric urolithiasis--a multivariate analysis study

OBJECTIVE

To define the predictive factors for the formation of steinstrasse (SS) after shock wave lithotripsy (SWL) and determine the treatment strategies for this complication in pediatric urolithiasis.

METHODS

We retrospectively reviewed the data of 341 renal units (RUs) treated with SWL for urolithiasis. The stone location, stone burden, auxiliary procedures, energy level, and number of shock waves were recorded. Statistical analysis was performed to detect the predictive factors for the formation of SS. In addition, the treatment of children with SS was evaluated.

RESULTS

The mean age of the children was 8.31 years (range 1-17). Episodes of SS developed in 26 RUs (7.6%). Of the 26 RUs, 20 (77%) were localized in the lower, 5 (19%) in the upper, and 1 (4%) in multiple locations in the ureter. The stone burden was the only statistically significant factor predicting the formation of SS on logistic regression analysis (P = .001). Of the 26 RUs, 17 (65.4%) were successfully managed by repeat SWL monotherapy, 4 (15.4%) were managed with ureteroscopy after failure of SWL, 1 (3.8%) was managed by ureteroscopy monotherapy, and 4 (15.4%) were monitored with conservative management with antispasmodic drug plus hydration therapy. The mean number of SWL sessions was 1.72.

CONCLUSION

The incidence of SS development in children after SWL treatment was similar to that in adult series. Our results suggest that the stone burden is a significant predictive factor for the development of SS after SWL in pediatric urolithiasis. Most children with SS could be easily and safely treated by repeat SWL.

Ureterorenoscopy: avoiding and managing the complications

Retrograde exploration of the ureter and kidneys is currently a widely used and well-established procedure to deal with problems of a diagnostic and therapeutic nature with reduced invasiveness. The process of miniaturizing the instruments combined with the steady improvement in video quality has continuously amplified its potential applications, maintaining the procedure safe and rapid. During an operation, however, unexpected events may condition a change to the programme or determine the onset of even more serious complications. Our aim is to analyze such events and complications and recommend potential solutions to prevent and/or deal with such happenings.

Minimally invasive management of urolithiasis

The management of urolithiasis has radically changed over the last two decades. Open surgery has been almost completely replaced by minimally invasive procedures, mainly extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS). Although these treatment modalities have been proven to be very safe and effective, serious complications can occur. Prompt diagnosis is often essential and may even be lifesaving. Radiologists play an important role in this setting, since many of these complications can be readily diagnosed by imaging. Awareness of the wide spectrum of complications may be crucial in interpreting imaging studies of patients who have undergone one of these procedures. This article reviews the contemporary management of ureteric stones with ESWL and URS and illustrates the radiological findings of complications of these procedures.

Role of tamsulosin in treatment of patients with steinstrasse developing after extracorporeal shock wave lithotripsy

OBJECTIVES

To evaluate whether tamsulosin, as an alpha(1)-blocker, was effective for the treatment of steinstrasse in the lower ureter after shock wave lithotripsy.

METHODS

A total of 67 patients (43 men and 24 women) with steinstrasse in the lower portion of the ureters were randomly divided into two groups. Only hydration and tenoxicam (20 mg orally once daily) was given to group 1 (35 patients). Group 2 (32 patients), was also given tamsulosin (0.4 mg daily). All patients were reevaluated and questioned about the number of episodes and severity of ureteral colic and the rates of spontaneous resolution of steinstrasse 6 weeks after beginning treatment. They were asked to score the severity of pain according to a visual analog scale.

RESULTS

In 23 (65.7%) of 35 patients in group 1 and in 24 (75%) of 32 patients in group 2, steinstrasse resolved during the first 6 weeks. The resolution rates were not significantly different (P >0.05) between groups 1 and 2. Group 1 had more ureteral colic episodes than did group 2 while passing their stones. This difference was statistically significant (P <0.01). Group 1 patients reported significantly greater (P <0.001) visual analog scale scores than did group 2 patients.

CONCLUSIONS

The addition of tamsulosin to conservative treatment seemed to be beneficial in terms of the reduced number of ureteral colic episodes and the severity of pain in the patients who developed steinstrasse after shock wave lithotripsy.

Complications of ureteroscopy

Ureteroscopy has undergone a dramatic evolution over the last two decades. Although ureteroscopic injury is the most common cause of ureteral trauma because of the large number of ureteroscopic procedures performed, improvements in instrumentation and technique have resulted in a reduced incidence of serious complications. Despite significant technologic advances, however, surgical misadventures still occur, some of which have lasting consequences. Careful attention to instrument selection and surgical technique are critical to reduce untoward events related to ureteroscopy. As such, adverse sequelae associated with ureteroscopy should be related to the underlying pathology itself rather than to the treatment.

Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management

OBJECTIVE

To determine the causes of steinstrasse, methods of prevention and treatment strategies.

PATIENTS AND METHODS

Fifty-two patients with steinstrasse were identified and treated: all patients were initially treated conservatively but when there was obstruction, infection or no progression of the stone fragments, further treatment was used, ranging from repeated extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrostomy (PCN), endoscopic manipulations and finally open surgery, depending on the degree of obstruction, infection, renal function and response to each kind of therapy.

RESULTS

Conservative management was successful in 25 patients (48%), repeated ESWL in 12 (23%), PCN in 10 (19%), ureteroscopy in three (6%) and open surgery in two (4%).

CONCLUSION

As many patients, and particularly those with larger stones, are treated by ESWL, the risk of developing steinstrasse will increase, with associated patient discomfort, infection or impaired renal function. The optimum selection of cases (aiming to pulverize the stones rather than fragment them) and accurate stone targeting are essential to minimise the development of steinstrasse. The meticulous follow-up of patients with steinstrasse should prevent any loss of renal function. When there is obstruction and/or infection or renal damage, active treatment is indicated, of which ESWL and PCN are the most effective, with ureteroscopy and open surgery reserved for difficult cases.

Steinstrasse: a comparison of incidence with and without J stenting and the effect of J stenting on subsequent management

OBJECTIVE

To analyse the effect of ureteric stenting on the incidence of steinstrasse and its effects on the subsequent management of steinstrasse.

PATIENTS AND METHODS

Four hundred adult patients with a unilateral stone burden (mean diameter 1.5-3.5 cm) were randomly allocated into two groups; in group 1, patients had a J stent inserted before extracorporeal shock wave lithotripsy (ESWL) and group 2 did not. Before randomization, the patients had normal renal function and no evidence of ureteric obstruction on intravenous urography. All patients underwent ESWL, with the shock waves delivered first to the most dependent part of the calculi. Patients who developed steinstrasse were identified and the effect of the size of the calculi and the presence of a J stent on the incidence and level of the steinstrasse, on the time of diagnosis, the size of the major stone fragment, associated presenting symptoms and effect on subsequent management were compared between the groups.

RESULTS

Patients developed steinstrasse in both groups, with 12 (6%) and 26 (13%) in groups 1 and 2, respectively (significantly different, P<0.05). The incidence of steinstrasse depended on the size of the calculus, regardless of whether a J stent was present, being 2.6% and 56% for a burden of 1.5-2.0 cm and 3.1-3.5 cm, respectively (P<0.001). There was no difference in the presenting symptoms in the two groups. The steinstrasse was in the lower third of the ureter in eight of 12 patients in group 1 and in 16 of 26 (62%) in group 2. The steinstrasse resolved spontaneously in seven patients in group 1 and in 12 (46%) in group 2 (P<0.11). Similarly, J stenting had no effect on the subsequent treatment modalities to resolve steinstrasse.

CONCLUSION

The use of J stenting before lithotripsy significantly lowers the incidence of steinstrasse in patients with a stone burden of 1.5-3.5 cm. The incidence of steinstrasse increases with the size of the calculi, whether or not a J stent is present; J stenting has no apparent effect on the mode of presentation or the subsequent management of steinstrasse.

The role of ureteral stent placement in the prevention of Steinstrasse

BACKGROUND AND OBJECTIVE

Steinstrasse constitutes a potentially serious complication of extracorporeal shock-wave lithotripsy (SWL). Ureteral stent placement has been used to prevent Steinstrasse after fragmentation of larger stones. However, particularly more recently, its preventive efficacy has been questioned. The aim of this study therefore was to analyze the role of ureteral stent placement in the prevention of Steinstrasse.

METHODS

We analyzed data of 1087 patients who had been treated with a Wolf Piezolith 2300 in the General Infirmary in Leeds/UK for stones ranging from 10 to 95 mm in diameter.

RESULTS

The incidence of Steinstrasse was 6.3%. The likelihood was significantly correlated with the stone size and was significantly less in patients with stones >20 mm if a stent had been inserted prior to SWL. Moreover, in these patients, the risk of acute clinical symptoms in the event of Steinstrasse was greatly reduced, and the treatment could be continued safely in the majority of cases (86%). Treatments of the Steinstrasse itself with SWL resulted in its clearance in most of the cases (78%). It was always possible to clear even extended persistent Steinstrasse by laser lithotripsy.

CONCLUSION

These results provide a clear indication for the pre-SWL insertion of a ureteral stent in patients with stones >20 mm in diameter. In the event of Steinstrasse, SWL of the collection should be tried before more invasive endourologic procedures are considered.

Treatment options in struvite stones

Urinary calculi have plagued man over the centuries. The epidemiology and pathogenesis of infection have been studied. The curative treatment remains problematic. Without therapy, a vicious cycle of stone formation occurs. This results in renal damage and even death. Multimodality therapy is the key. Nonoperative treatment leads to progressive renal damage. The combination of maximal surgical ablation and medical therapy is synergistic. The combination of PCNL-ESWL has not appeared to produce ill effects. PCNL-ESWL is a less morbid surgical alternative than open surgical procedures. Adjunctive medical therapy, such as culture-specific antibiotics and urease inhibitors, complements surgical ablation by reducing the morbidity with persistent UTIs and stone recurrence. The urologist today must approach struvite staghorns with a vast armamentarium of surgical and medical techniques. Each patient requires a unique solution.

“Steinstrasse” or stone street after extracorporeal lithotripsy

The aim of this work has been to check the frequency and to assess which manoeuvres are necessary in treating the steinstrasse after ESWL in situ. From September 1989 to May 1996, 2400 patients were treated with extracorporeal lithotripsy, 86 (3.6%) developed a steinstrasse in the days immediately after treatment. Only 40% of cases had specific urinary obstruction symptoms. In 52 patients (60%) the steinstrasse was spontaneously eliminated within 4 weeks, while in the remaining 34 an auxiliary treatment was necessary (second ESWL, percutaneous nephrostomy, ureteroscopic management). These therapies required further hospital admittance but didn't cause statistically significant differences in the stone-free rate at 6 months (96% and 97%, p < 0.001). Our experience would indicate that the incidence of steinstrasse after ESWL in situ is quite low (3.6%) and the necessity for auxiliary treatment is extremely rare (1.4%).

In situ piezoelectric extracorporeal shock wave lithotripsy of ureteric stones

OBJECTIVE

To evaluate the efficacy of the EDAP LT 02 lithotripter for the in situ treatment of ureteric calculi.

PATIENTS AND METHODS

One hundred consecutive patients presenting with ureteric calculi were treated with in situ piezoelectric extracorporeal shock wave lithotripsy (ESWL) using the EDAP LT 02 lithotripter. There were 49 patients with upper, nine with mid and 42 with lower ureteric stones. The largest diameter of the stones varied from 7 to 21 mm (mean 9.6 mm). Mild or severe hydronephrosis was present in 53 cases. Mid and lower ureteric stones were treated with the patients in the prone position, with no anaesthesia or pre-medication, and upper ureteric stones in the supine position, with intravenous sedation in 44 cases.

RESULTS

Localization of the stones was easy in 81 cases and more difficult in 19, but an intravenous pyelogram was only necessary in three cases. The number of sessions per patient varied from 1 to 3 (mean 1.17). Complete success rate was achieved in 75% of patients and partial success (residual stones < or = 3 mm) in 6%. The stone-free rate was statistically affected by stone size but was independent of stone localization or the degree of obstruction. The rate of infective and obstructive complications was 14% and auxiliary treatments were necessary in 5% of patients.

CONCLUSION

In situ piezoelectric ESWL with the EDAP LT 02 device is a convenient and efficient method for the treatment of ureteric stones.

Analysis of stone fragility in vitro and in vivo with piezoelectric shock waves using the EDAP LT-01

A total of 100 whole stones was fragmented in vitro at 3-minute intervals with piezoelectric shock waves using the EDAP LT-01 device until all fragments were less than 2 mm. Larger stones and stones with a high computerized tomography attenuation needed longer treatments for fragmentation. Smoothly bulging stones with an even structure according to plain x-ray films were also more resistant to the shock wave treatment. Calcium oxalate monohydrate stones were not more difficult to break than other types of calculi. Stone fragments from 100 patients after extracorporeal shock wave lithotripsy were also analyzed. The average size of the fragments collected was less than 1 mm. Larger stones produced larger fragments and required more treatment sessions.