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Does the type of steinstrasse predict the outcome of expectant therapy?

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Author(s): Goyal Rajiv | Dubey Deepak | Khurana Naval | Mandhani Anil | Ansari M | Srivastava Aneesh | Kapoor Rakesh | Kumar Anant

Journal: Indian Journal of Urology
ISSN 0970-1591

Volume: 22;
Issue: 2;
Start page: 135;
Date: 2006;
Original page

Keywords: Classification | extracorporeal shock wave lithotripsy | management; steinstrasse

ABSTRACT
OBJECTIVES: To determine the outcome of expectant therapy in steinstrasse according to its type. MATERIALS AND METHODS: A chart review was performed on patients who underwent extracorporeal shock wave lithotripsy (SWL) between 1995 and June 2004. Demographic profile, stone size, site, characteristics of steinstrasse (type 1; multiple small fragments, type 2; lead fragment of 5 mm or more with small fragments proximal to it and type 3; multiple fragments of 5 mm or more) and mode of treatment used, were noted. Patients of steinstrasse, diagnosed on X-Ray KUB were kept on expectant treatment for 4 weeks. Patients with high grade fever and infected hydronephrosis were treated with percutaneous nephrostomy (PCN) insertion. Non responders at 4 weeks, were treated with SWL and/or ureterorenoscopy (URS). RESULTS: 1000 patients of mean age 37.85 years, with urinary stones, received SWL (827 renal stones and 173 ureteric stones). Sixty patients (6%) developed steinstrasse. Mean stone size was 2.03 cm (0.6-4 cm). Type 1, 2 and 3 steinstrasse was present in 32 (53%), 20 (33%) and 8 (13%) patients, respectively. Conservative management was successful in 30 (50%) patients at 4 weeks. 3 patients who presented with infected hydronephrosis, required PCN. The remaining (27 patients) were subjected to repeat SWL. 24 of these 27 patients could be successfully treated with SWL, whereas the remaining 3 required URS. Of non- responders to conservative treatment i.e., 30 patients, 17 (56%) and 8 (26%) patients had type 2 and 3 steinstrasse respectively, whereas only 3 out of 30 (10%) responders had type 2 and none of the responders had type 3 steinstrasse, P value < 0.01. CONCLUSION: Type 2 and 3 steinstrasse have 90% (25 out of 28 failed) chance of not responding to the conservative treatment at 4 weeks. To avoid the risk of infected hydronephrosis (5%), active intervention should be done in patients with lead fragment of 5 mm or more (type 2 and 3 steinstrasse), as early as possible. SWL is successful in most of these patients and should be the primary modality of treatment.

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