Parmar K. et al., 2021: Large spontaneous steinstrasse: Our experience and management issues in tertiary care centre
Parmar K, Manoharan V, Kumar S, Ranjan KR, Chandna A, Chaudhary K.
Department of Urology, PGIMER, Chandigarh, India.
Abstract
Background: Steinstrasse, is described as array of stone pieces in the ureter following extracorporeal shock wave lithotripsy (SWL). It is well-recognized, transient event. Steinstrasse clears spontaneously, however about 6% require intervention. Spontaneous steinstrasse without prior history of SWL is a rare occurrence and only few case reports are published in literature. Objective of the study was to assess the aetiology and management issues of large spontaneous steinstrasse in our centre.
Method: From February 2017 to March 2019, 684 patients underwent SWL for renal or ureteric stones. Twenty-eight patients presented with steinstrasse of which nine patients had no prior history of SWL. Detailed clinical profile and management issues have been discussed.
Result: Among the nine patients of spontaneous steinstrasse, there were six males and three females. Mean age of the patients was 39 years (±13 years SD). Bilateral large spontaneous steinstrasse was seen in one out of nine patients. Seven patients had associated renal stones. Five patients presented with obstructive uropathy and three out of them had urosepsis as initial presentation. Ureterolithotomy and percutaneous nephrolithotomy were commonly performed procedures for stone clearance. Metabolic work was done in all cases in follow up period. Three patients had hypercalciuria and hypocitraturia suggestive of renal tubular acidosis.
Conclusion: Large spontaneous steinstrasse is uncommon case scenario. It can be subtle in presentation and yet have significant patient consequence in terms of renal function and infection. Prompt management is essential to preclude permanent loss of renal function. Metabolic evaluation is indispensable in such cases.
Urologia. 2021 Mar 14:3915603211001174. doi: 10.1177/03915603211001174. Online ahead of print. PMID: 33719767
Comments 1
This article discusses the management of patients with steinstrasse after stone disintegration (SWL) in general and particularly the problem of the less common spontaneous steinstrasse. Of 28 patients in whom steinstrasse was diagnosed in the author´s department 9 had accumulation of stones in the ureter without preceding SWL.
Steinstrasse is a problematic condition that causes obstruction to the urine flow, might be associated with infection complications and technically difficult to deal with.
The authors treated 5 of their 9 patients with open surgery (!) and one with ureteroscopy. PCNL was used alone or in combination with other surgical procedures in 8 patients.
My own exceedingly early experience of steinstrasse after SWL in the 1980-ies was that ureteroscopy was the least attractive therapeutic approach. Although technical developments have improved endourology in this regard, my own strategy has been to decompress the renal collecting system with either an internal stent or a percutaneous nephrostomy catheter and then disintegrate the stone material in the ureter with SWL. That method almost always has been successful.
Sometimes subsequent deposition of jelly in the ureter was helpful for improving fragment passage.
One important observation in this article was that 6 of the patients with spontaneous steinstrasse had stones composed of calcium phosphate. Only 3 were calcium oxalate stones. For those patients with calcium phosphate stones in whom percutaneous nephrostomy was used for decompression, it had indeed been interesting to see what could have been achieved with a combination of SWL and chemolysis.
Most certainly open surgery was a radical treatment method for rapid and optimal clearance, but it is not the least invasive approach.
Hans-Göran Tiselius