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Multiple ureterolithiasis resembling steinstrasse: An unusual presentation
Urological Science xxx (2014) 1e2
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Case report
Multiple ureterolithiasis resembling steinstrasse: An unusual presentation Praveen Kumar Pandey a, *, Suruchi Shukla b, Anup Kumar Kundu a, Pramod Kumar Sharma a, Mukesh Kumar Vijay a a b
Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata 700020, India Department of Microbiology, Sagar Dutta Medical College, Kolkata 700058, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 May 2012 Received in revised form 19 June 2012 Accepted 28 September 2012 Available online xxx
Steinstrasse or “stone street” is an expected complication after extracorporeal shock wave lithotripsy in patients with high stone burden. However, there are published reports of multiple ureterolithiasis resembling steinstrasse in patients with distal renal tubular acidosis. Here we report an uncommon case of a 60-year-old woman who presented with right renal calculi. Her right ureter was studded with multiple calculi up to the vesicoureteric junction. The affected right kidney was nonfunctional and was managed by nephroureterectomy. Copyright © 2014, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: lithotripsy renal colic ureterolithiasis
1. Introduction Multiple ureterolithiasis is an entity that may be incidentally diagnosed in patients with renal or ureteric colic pain. There is a higher possibility that nonobstructive calculi are present in such a manner because they produce fewer symptoms.1 The objective of this report was to highlight the radiological findings and management of a condition resembling steinstrasse or “stone street” in a case of multiple right ureteric calculi. 2. Case Report A 60-year-old woman presented at our institution with a 7-year history of right flank pain. The pain was mild, intermittent, and radiating to the right groin. She had gradually become dependent on analgesics over a period of time. The kidney, ureter, and bladder X-ray (Fig. 1) showed right renal calculi, and the right ureter was filled with multiple calculi up to the vesicoureteric junction. The patient had no history of extracorporeal shock wave lithotripsy (SWL) for the renal calculi. Her serum electrolyte levels were normal. Her urine pH was 6.5, 24-hour urinary calcium was 156 mg, and 24-hour urinary citrate was 310 mg. * Corresponding author. Department of Urology, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, 244, AJC Bose Road, Kolkata 700020, India. E-mail address: [email protected] (P.K. Pandey).
Urine culture showed no growth and differential leukocyte counts were within normal range. Serum urea and creatinine were 22 mg/ dL and 0.9 mg/dL, respectively. Subsequently, intravenous urography was performed, which revealed a nonexcreting right kidney and a normal-functioning left kidney (Fig. 2). Further, a technetium99m (99mTc)-diethylenetriaminepentaacetic acid renal scan was performed to evaluate the differential function of the right kidney. The scan confirmed that the right kidney was nonfunctional. After counseling, the patient underwent a right nephroureterectomy for symptom relief. An open surgical approach was adopted because a significant amount of adhesions were anticipated in the surrounding tissues of the right kidney. On exploration, right hydronephrosis with calculi was observed and the right ureter was filled with multiple calculi up to the vesicoureteric junction. Histopathological findings were suggestive of pyelonephritic kidney with infective changes in the ureter. The patient is on regular follow up and is doing well. 3. Discussion Steinstrasse is an aggregation of particles in the ureter usually formed following extracorporeal SWL. It is a common radiological finding that occurs in approximately 15% of cases after SWL.2 However, a steinstrasse-resembling entity in the absence of SWL has been reported in patients with distal renal tubular acidosis (DRTA).3 DRTA is a metabolic abnormality that may
http://dx.doi.org/10.1016/j.urols.2012.09.002 1879-5226/Copyright © 2014, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Pandey PK, et al., Multiple ureterolithiasis resembling steinstrasse: An unusual presentation, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2012.09.002
2
P.K. Pandey et al. / Urological Science xxx (2014) 1e2
Fig. 1. Radiograph of the kidney, ureter, and bladder showing right renal calculi and the right ureter filled with multiple calculi.
present with nephrocalcinosis and spontaneous steinstrasse. The chief reason for calculi formation in DRTA is hypercalciuria and hypocitraturia. However, our patient had no such metabolic abnormality. Such patients may present with partial or complete ureteral obstruction that could be complicated with superimposed urinary tract infection. The presence of such a large stone burden in the absence of a metabolic abnormality in our case may be because of abnormal dietary habits, decreased fluid intake, and environmental factors. However, the left kidney was surprisingly spared in our case. After SWL, almost 30% of the patients may have obstruction of the ipsilateral ureter without any symptoms at all. Subsequently, this obstruction may result in compromised renal function.4 Patients with steinstrasse may be initially treated conservatively. However, if the obstruction is associated with ureteral colic, further treatment options are considered. These options may include percutaneous nephrostomy, endoscopic manipulation, and eventually open surgery in cases where previous treatments have failed.5e7 Many patients refuse definitive treatment for renal and ureteric calculi. Our patient had been neglecting her symptoms for 6e7 years and presented to us with severe flank pain and nausea. Further, this condition is sometimes troublesome and may be complicated by bacteremia or septicemia.8 In conclusion, our patient was symptomatic over a long period of time, and there was documented loss of function of her right
Fig. 2. Intravenous urography film showing no contrast excretion from the right kidney.
kidney. Therefore, a right nephroureterectomy was performed to relieve her symptoms and eliminate the probability of infection in the near future. Conflicts of interest All contributing authors declare no conflicts of interest. References 1. Sabnis RB, Desai RB, Bradoo AM, Punekar SV, Bapat SD. Giant ureteral stone. J Urol 1992;148:861e2. 2. Coptcoat MJ, Webb DR, Kellet MJ, Whitfield HN, Wickham JE. The steinstrasse: A legacy of extracorporeal lithotripsy? Eur Urol 1988;14:93e5. 3. Homayoon K. Spontaneous steinstrasse due to renal tubular acidosis. Br J Urol 1996;77:610e1. 4. Madbouly K, Sheir KZ, Elsobky E, Eraky I, Kenawy M. Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: a statistical model. J Urol 2002;167:1239e42. 5. Satar N, Doran S, Ozkeceli R, Turkyilmaz RK. Treatment of multiple small stone particles (steinstrasse) in the lower ureter after the extracorporeal shock wave lithotripsy treatment. Tr J Med Sci 1998;28:269e71. 6. Sayed MA, el-Taher AM, Aboul-Ella HA, Shaker SE. Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management. BJU Int 2001;88:675e8. 7. Goyal R, Dubey D, Khurana N, Mandhani A, Ansari MS, Srivastava A, et al. Does the type of steinstrasse predict the outcome of expectant therapy? Indian J Urol 2006;2:135e8. 8. Salem S, Mehrsai A, Zartab H, Shahdadi N, Pourmand G. Complications and outcomes following extracorporeal shock wave lithotripsy: a prospective study of 3,241 patients. Urol Res 2010;38:135e42.
Please cite this article in press as: Pandey PK, et al., Multiple ureterolithiasis resembling steinstrasse: An unusual presentation, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2012.09.002
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Case report
Multiple ureterolithiasis resembling steinstrasse: An unusual presentation Praveen Kumar Pandey a, *, Suruchi Shukla b, Anup Kumar Kundu a, Pramod Kumar Sharma a, Mukesh Kumar Vijay a a b
Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata 700020, India Department of Microbiology, Sagar Dutta Medical College, Kolkata 700058, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 May 2012 Received in revised form 19 June 2012 Accepted 28 September 2012 Available online xxx
Steinstrasse or “stone street” is an expected complication after extracorporeal shock wave lithotripsy in patients with high stone burden. However, there are published reports of multiple ureterolithiasis resembling steinstrasse in patients with distal renal tubular acidosis. Here we report an uncommon case of a 60-year-old woman who presented with right renal calculi. Her right ureter was studded with multiple calculi up to the vesicoureteric junction. The affected right kidney was nonfunctional and was managed by nephroureterectomy. Copyright © 2014, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: lithotripsy renal colic ureterolithiasis
1. Introduction Multiple ureterolithiasis is an entity that may be incidentally diagnosed in patients with renal or ureteric colic pain. There is a higher possibility that nonobstructive calculi are present in such a manner because they produce fewer symptoms.1 The objective of this report was to highlight the radiological findings and management of a condition resembling steinstrasse or “stone street” in a case of multiple right ureteric calculi. 2. Case Report A 60-year-old woman presented at our institution with a 7-year history of right flank pain. The pain was mild, intermittent, and radiating to the right groin. She had gradually become dependent on analgesics over a period of time. The kidney, ureter, and bladder X-ray (Fig. 1) showed right renal calculi, and the right ureter was filled with multiple calculi up to the vesicoureteric junction. The patient had no history of extracorporeal shock wave lithotripsy (SWL) for the renal calculi. Her serum electrolyte levels were normal. Her urine pH was 6.5, 24-hour urinary calcium was 156 mg, and 24-hour urinary citrate was 310 mg. * Corresponding author. Department of Urology, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, 244, AJC Bose Road, Kolkata 700020, India. E-mail address: [email protected] (P.K. Pandey).
Urine culture showed no growth and differential leukocyte counts were within normal range. Serum urea and creatinine were 22 mg/ dL and 0.9 mg/dL, respectively. Subsequently, intravenous urography was performed, which revealed a nonexcreting right kidney and a normal-functioning left kidney (Fig. 2). Further, a technetium99m (99mTc)-diethylenetriaminepentaacetic acid renal scan was performed to evaluate the differential function of the right kidney. The scan confirmed that the right kidney was nonfunctional. After counseling, the patient underwent a right nephroureterectomy for symptom relief. An open surgical approach was adopted because a significant amount of adhesions were anticipated in the surrounding tissues of the right kidney. On exploration, right hydronephrosis with calculi was observed and the right ureter was filled with multiple calculi up to the vesicoureteric junction. Histopathological findings were suggestive of pyelonephritic kidney with infective changes in the ureter. The patient is on regular follow up and is doing well. 3. Discussion Steinstrasse is an aggregation of particles in the ureter usually formed following extracorporeal SWL. It is a common radiological finding that occurs in approximately 15% of cases after SWL.2 However, a steinstrasse-resembling entity in the absence of SWL has been reported in patients with distal renal tubular acidosis (DRTA).3 DRTA is a metabolic abnormality that may
http://dx.doi.org/10.1016/j.urols.2012.09.002 1879-5226/Copyright © 2014, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Pandey PK, et al., Multiple ureterolithiasis resembling steinstrasse: An unusual presentation, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2012.09.002
2
P.K. Pandey et al. / Urological Science xxx (2014) 1e2
Fig. 1. Radiograph of the kidney, ureter, and bladder showing right renal calculi and the right ureter filled with multiple calculi.
present with nephrocalcinosis and spontaneous steinstrasse. The chief reason for calculi formation in DRTA is hypercalciuria and hypocitraturia. However, our patient had no such metabolic abnormality. Such patients may present with partial or complete ureteral obstruction that could be complicated with superimposed urinary tract infection. The presence of such a large stone burden in the absence of a metabolic abnormality in our case may be because of abnormal dietary habits, decreased fluid intake, and environmental factors. However, the left kidney was surprisingly spared in our case. After SWL, almost 30% of the patients may have obstruction of the ipsilateral ureter without any symptoms at all. Subsequently, this obstruction may result in compromised renal function.4 Patients with steinstrasse may be initially treated conservatively. However, if the obstruction is associated with ureteral colic, further treatment options are considered. These options may include percutaneous nephrostomy, endoscopic manipulation, and eventually open surgery in cases where previous treatments have failed.5e7 Many patients refuse definitive treatment for renal and ureteric calculi. Our patient had been neglecting her symptoms for 6e7 years and presented to us with severe flank pain and nausea. Further, this condition is sometimes troublesome and may be complicated by bacteremia or septicemia.8 In conclusion, our patient was symptomatic over a long period of time, and there was documented loss of function of her right
Fig. 2. Intravenous urography film showing no contrast excretion from the right kidney.
kidney. Therefore, a right nephroureterectomy was performed to relieve her symptoms and eliminate the probability of infection in the near future. Conflicts of interest All contributing authors declare no conflicts of interest. References 1. Sabnis RB, Desai RB, Bradoo AM, Punekar SV, Bapat SD. Giant ureteral stone. J Urol 1992;148:861e2. 2. Coptcoat MJ, Webb DR, Kellet MJ, Whitfield HN, Wickham JE. The steinstrasse: A legacy of extracorporeal lithotripsy? Eur Urol 1988;14:93e5. 3. Homayoon K. Spontaneous steinstrasse due to renal tubular acidosis. Br J Urol 1996;77:610e1. 4. Madbouly K, Sheir KZ, Elsobky E, Eraky I, Kenawy M. Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: a statistical model. J Urol 2002;167:1239e42. 5. Satar N, Doran S, Ozkeceli R, Turkyilmaz RK. Treatment of multiple small stone particles (steinstrasse) in the lower ureter after the extracorporeal shock wave lithotripsy treatment. Tr J Med Sci 1998;28:269e71. 6. Sayed MA, el-Taher AM, Aboul-Ella HA, Shaker SE. Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management. BJU Int 2001;88:675e8. 7. Goyal R, Dubey D, Khurana N, Mandhani A, Ansari MS, Srivastava A, et al. Does the type of steinstrasse predict the outcome of expectant therapy? Indian J Urol 2006;2:135e8. 8. Salem S, Mehrsai A, Zartab H, Shahdadi N, Pourmand G. Complications and outcomes following extracorporeal shock wave lithotripsy: a prospective study of 3,241 patients. Urol Res 2010;38:135e42.
Please cite this article in press as: Pandey PK, et al., Multiple ureterolithiasis resembling steinstrasse: An unusual presentation, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2012.09.002