M. A. Elbaset et al., 2024: Ureteral wall thickness as a predictor for non-invasive treatment success for steinstrasse. Can we save time?
M A Elbaset, Diaa-Eldin Taha, Marwan Anas, Ahmed Elghareeb, Rasha T Abouelkheir, Rawdy Ashour, K Z Sheir, Yasser Osman
Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
Urology Department, Horus University, New Damietta, Egypt.
Urology Department, KafrELshiekh University, KafrELshiekh, Egypt.
Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
Radiology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
Abstract
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.
World J Urol. 2024 Mar 13;42(1):151. doi: 10.1007/s00345-024-04874-w. Authors
PMID: 38478098 FREE PMC ARTICLE
Comments 1
Ever since the introduction of ESWL, steinstrasse, an accumulation of stone fragments in the ureter with obstruction, has been a feared complication. Apart from conservative measures, URS was considered as the only way to solve the problem. Removal of a leading fragment was the key step, but if there only was a large volume of fragments the success with URS was limited.
In this article different procedures to deal with steinstrasse are discussed and the conclusion was that ureteral wall thickness (UWT) is an important predictor. However, UWT was not possible to measure before the introduction of CT. Edema in the ureteral wall develops when stone fragments cause obstruction and cause inflammation in the ureter.
The conclusion drawn in this report is that when 4 weeks of MET led to decreased UWT, successful elimination can be expected in a large number of patients.
Comment by the reviewer:
In my own experience the best way to handle this problem has been to pre-treat with a stent when a large volume of fragments is expected. Local SWL towards the steinstrasse, usually is a successful method. To avoid anesthesia-requiring endoscopy (URS), the reviewer has inserted an internal stent or ureteral catheter following lubrication with diluted xylocaine or lidocaine gel and then proceed with SWL. The whole procedure can be carried out without anesthesia and only with local anesthesia and analgesics. During decades the reviewer successfully has applied this method to avoid invasive URS. Only exceptionally has it become necessary to use URS.
Hans-Göran Tiselius