Lessons learned in patients with large steinstrasse

Experience with 19 patients (25 ureters) who suffered the complication of a large steinstrasse (a third or more of the ureteral length) has led to lessons regarding the management of this complication as well as to insights into patient presentation, metabolic consequences, and the efficiency of diagnostic and therapeutic modalities. Few symptoms were present in a large percentage of patients despite urinary obstruction, decreased renal function, infection and in several cases impending sepsis. Large stone burdens, bilateral treatment, inability to debulk stone burden before extracorporeal shock wave lithotripsy and unexpected fragment movement were definite predisposing factors in the development of this complication. Double pigtail stents and percutaneous nephrostomy alone did not always prevent or resolve the problem. Combined use of percutaneous nephrostomy and ureteroscopic ultrasonic or laser lithotripsy appears to be the most effective treatment modality in patients who fail brief observation. This approach can be combined under appropriate circumstances with a secondary extracorporeal shock wave lithotripsy or percutaneous nephrolithotripsy treatment in the staged management of complex upper urinary tract calculous disease.