Severe Steinstrasse Post Utereroscopy: A Case Report

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Introduction: Steinstrasse or ‘Stone Street’ is an accumulation of stone fragments or gravel in the ureter which may cause a downstream obstruction to urine flow.1 It constitutes a potentially serious complication of treatment of large renal calculi, by surgery or use of extracorporeal shockwave lithotripsy (SWL). Steinstrasse occurs in 4-7% of patients treated with SWL.2 Stone size remains to be a major determinant in the development of Steinstrasse, especially those greater than 20mm.3

The European Association of Urology (EAU) has published its guidelines on the treatment of renal stones.4 Stones up to 20mm in the renal pelvis, upper or middle calyces can be treated with SWL or endourology. Endourology reduces the need for repeated procedures and consequently a shorter time until stone-free status is achieved. A meta-analysis compared the use of SWL and retrograde intrarenal surgery and found that the latter provided a higher stone-free rate and lower retreatment rate.5 Stones greater than 20mm should be treated primarily by percutaneous nephrolithotomy (PCNL) unless contraindicated.

Case presentation: A 68-year-old man presented to the urology department with left-sided loin pain and haematuria. He was investigated with a flexible cystoscopy and CT urogram. Flexible cystoscopy was unremarkable, but CT urogram revealed a 20mm stone in his left renal pelvis. The patient subsequently had a left-sided flexible ureteroscopy with laser disintegration of stone, and a double J stent was inserted intraoperatively. The procedure was performed by a general urologist who does not specialize in stone disease. The patient’s stent was removed after one week. However, he represented three days later with severe left sided loin pain. A CT scan was performed which revealed severe steinstrasse disease.

 

Figures A & B. CT KUB showing severe steinstrasse disease

The patient had a double J stent inserted as an emergency procedure and was then brought back and operated on by a specialist endourologist. Findings include over 100 tiny stones lodged in the mid to upper ureter. These stones were extracted by basket retrieval. A few residual fragments were also removed from the left kidney itself. The ureter was found to be grossly oedematous after it was completely cleared. A ureteric stent was inserted to allow edema to settle. The stent was removed two weeks later. A CT KUB was repeated eight weeks post-procedure, showing a complete stone-free status.

Figure C. CT KUB 8 weeks post-op: stone free

Discussion: The severity of steinstrasse disease should not be underestimated. A significant problem with steinstrasse is ureteral obstruction and subsequent loss of renal function, which can be silent in up to 23% of patients.6

The EAU has published guidelines on the management of patients with steinstrasse disease.4 Conservative management is an initial option for asymptomatic patients. Medical expulsion therapy increases the stone expulsion rate of steinstrasse and reduces the endoscopic intervention. In severe cases where the patient is symptomatic, such as this case, ureteroscopy and SWL are effective in the treatment. The British Association of Urological Surgeons (BAUS) recommends ureteroscopy as the preferred modality, unless there is a large leading stone amenable to SWL.7 However if the patient is has a urinary tract infection (UTI) or fever, EAU recommends urgent decompression of the kidney, preferably by percutaneous nephrostomy.4

A further key point to take away is endourological procedures should always be performed by an expert endourologist, especially in complicated cases such as this. Patients should be also aware of the complications of surgery, including the potential need for further intervention.

In conclusion, we present a patient with severe steinstrasse disease after a flexible ureteroscopy and laser disintegration of stone, who was subsequently managed by an expert endourologist and is now stone free.

Written by: Anton Wong, MD, and Wasim Mahmalji, MBBS, BSC, MSC, FRCS (Urol), Nuffield Health Hereford Hospital, Hereford, England

References:

  1. Coptcoat, M. J., D. R. Webb, M. J. Keilet, H. N. Whitfield, and J. E. A. Wickham. “The steinstrasse: a legacy of extracorporeal lithotripsy?.” Journal of Urology (1989) Feb;141(2):466–466.
  2. Ather, M. Hammad, B. Shrestha, and Amber Mehmood. “Does ureteral stenting prior to shock wave lithotripsy influence the need for intervention in steinstrasse and related complications?.” Urologia Internationalis 83, no. 2 (2009): 222-225.
  3. Lucio II, Jarques, Fernando Korkes, Antonio Corrêa Lopes-Neto, Edward Gomes Silva, Mário Henrique Elias Mattos, and Antonio Carlos Lima Pompeo. “Steinstrasse predictive factors and outcomes after extracorporeal shockwave lithotripsy.” International braz j urol 37, no. 4 (2011): 477-482.
  4. Türk C, Petřík A, Sarica K, Seitz C, Skolarikos A, Straub M, et al. “EAU Guidelines on Interventional Treatment for Urolithiasis.” European Urology [Internet]. 2016 Mar [cited 2019 Mar 1];69(3):475–82. Available from:  https://www.sciencedirect.com/science/article/pii/S0302283815007009
  5. Zheng, Changjian, Hongmei Yang, Jun Luo, Bo Xiong, Hongzhi Wang, and Qing Jiang. “Extracorporeal shock wave lithotripsy versus retrograde intrarenal surgery for treatment for renal stones 1–2 cm: a meta-analysis.” Urolithiasis 43, no. 6 (2015): 549-556.
  6. Madbouly, Khaled, Khaled Z. Sheir, Emad Elsobky, Ibrahim Eraky, and Mahmoud Kenawy. “Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: a statistical model.” The Journal of urology 167, no. 3 (2002): 1239-1242.
  7. Walton T. “Management of renal and ureteric stones.” [Internet]. 2011 [cited 2020 Jul 7]. Available from: https://www.baus.org.uk/_userfiles/pages/files/professionals/bsot/TJW-Mx-Renal-and-Ureteric-Stones.pdf
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