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It is my pleasure and an honour to write an editorial about a very important paper published in 1988, mainly because Malcolm Coptcoat was an excellent scientist and a prominent member of that group of young European urologists who opened the way to modern endourology in the 1980s.
Together with all the formerly young endourologists, I still miss a great urologist and a very good friend.
The term “steinstrasse” witnesses the German origin of extracorporeal shock wave lithotripsy (ESWL) and has never been translated. The classification of three types proposed in the Coptcoat article was not widely used in clinical practice. However, the principles of diagnosis and treatment of steinstrasse described in 1988 are still valid.
Stone size and site, renal morphology, and shock wave energy are the significant predictive factors controlling steinstrasse formation [1].
Prevention of steinstrasse formation may be achieved by ureteral stenting before ESWL, even if controversy still exists about doing so. Several years ago, the Njimegen group [2] reported results of a randomised trial in which ureteral stents did not reduce complications after ESWL.
Stents were associated with morbidity and did not markedly improve stone passage. However, several other important, more recent studies [3], [4] advocated the use of J-stents before ESWL in stones >2cm in diameter. In the Sulaiman study of 1087 patients, the incidence of steinstrasse was significantly lower in patients with stones >20mm if a stent had been inserted prior to ESWL. On the other hand, most guidelines no longer suggest ESWL for stones >2cm in diameter [5], so that the incidence of steinstrasse should be reduced by the expanding use of percutaneous surgery.
As advocated by Coptcoat, asymptomatic steinstrasse should be managed conservatively with weekly radiologic and ultrasound examinations until the particles pass spontaneously. Recent papers [6], [7] suggest that the addition of tamsulosin to conservative treatment may be beneficial in reducing the number of colic episodes and shortening expulsion time.
Complicated steinstrasse (pain, hydronephrosis, fever) should be treated aggressively with percutaneous drainage, ureteroscopy, or both. Simple J-stenting is not an effective option.
The loss of renal units following steinstrasse is possible if the ESWL follow-up is suboptimal. However, in this period of “economical” medicine the cost of a meticulous follow-up after ESWL might be considered too high. Urologists should be aware that the incidence of steinstrasse, although rare, is still possible and may constitute a potentially serious complication if not investigated carefully.
References
1. Madbouly K, Sheir Kz, Elsobky E, Eraky I, Kenawi M. Risk factors for the stone formation of a steinstrasse after extracorporeal shock wave lithotripsy. J Urol. 2002;167:1239.
2. Bierkens AF, Hendrikx AJ, Lemmens WA, Debruyne FM. Extracorporeal shock wave lithotripsy for large renal calculi: the role of ureteral stents. A randomized trial. J Urol. 1991;145:699.
3. Sulaiman MN, Bucholz NP, Clark PB. The role of ureteral stent placement in the prevention of steinstrasse. J Endourol. 1999;13:151.
4. Al-Awadi KA, Abdul Halim H, Kehinde EO, Al-Tawheed A. Steinstrasse: a comparison of incidence with and without J stenting and the effect of J stenting on subsequent management. BJU Int. 2000;85:561.
5. EAU Guidelines on Urolithiasis.
6. Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones. J Urol. 2003;170:2202.
7. Resim S, Ekerbiker HC, Ciftci A. Role of tamsulosin in treatment of patients with steinstrasse developing after extracorporeal shock wave lithotripsy. Urology. 2005;66:945.
Paolo Puppo
Department of Surgical Oncology, Urology Unit, IST – Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
published online 20 July 2006.
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