Rabie M Ibrahim et. al., 2024: Extracorporeal shock wave lithotripsy versus laser lithotripsy in the treatment of post-SWL steinstrasse: a randomized comparative study
Rabie M Ibrahim 1 , Osama Sayed 2 , Amr M Lotfy 2 , Hossam Sultan 2 , Akrm A Elmarakbi 2
1Department of Urology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.
2Department of Urology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.
Abstract
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.
World J Urol. 2024 May 22;42(1):345. doi: 10.1007/s00345-024-05046-6. PMID: 38777909
Comments 1
The accumulation of fragments with or without a leading stone is termed steinstrasse. The clinical effects are obstruction, fever, infection and pain, and the clinical stone problem has not been solved until these ureteral fragments are eliminated and urine flow re-established.
Steinstrasse is a complication most seen after SWL of large stones. Its prevention by pre-stenting in case of stones measuring > 15-20 mm has made this complication unusual.
It is not mentioned what caused the steinstrasse in the randomized patients described in this report. Moreover, it is unknown how commonly this complication occurs after modern SWL. Undoubtedly, modern ureteroscopy has made endoscopic treatment of steinstrasse much easier than was the case during the early days of SWL.
In the reported randomized study stone clearance was recorded in 100% after URS and in 83% after two sessions of SWL. In the reviewer’s eyes, the obvious shortcoming of URS, is that stone fragments were endoscopically pushed to the kidney where disintegration had to be carried out. The longer treatment for SWL mentioned in the Abstract seems to be incorrect information that differs from what can be found in the Results section.
In my own extensive experience URS for treatment of steinstrasse was necessary only occasionally. Instead, all ureteral fragments were successfully treated with in situ SWL with or without gentle auxiliary procedures not requiring more than local anesthesia. Accordingly, SWL was carried out in situ in prone or supine position. This was enough as the only procedure in case of short accumulations of fragments. In more complex cases, a guidewire was inserted under fluoroscopy, before or after re-SWL and lubrication of the fragments was made by diluted lidocaine jelly. Finally, a stent was inserted and left in place for facilitated fragment elimination.
The latter approach in my hands never required general or regional anesthesia but was easily completed with local anesthesia and when needed with small intermittent doses of analgesics. A diuretic regimen subsequently facilitated fragment clearance.
Hans-Göran Tiselius