Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease

Подождите немного. Документ загружается.

536 Urena, Mendez-Torres, and Thomas

2. Pneumatic lithotriptor, which uses compressed nitrogen gas to launch a projectile against

the handheld probe head, creating repeated impacts between the probe tip and the stone

surface. Once the tensile forces of the stone are reached, stone breakage is obtained.

There is an increased chance for proximal stone migration secondary to repeated impact.

Although ureteral perforation can occur secondary to pneumatic lithotriptor use, the

short burst of energy results only in superficial erosion or edema without subsequent

complications (222).

3. EHL was the first modality of intracorporeal lithotripsy available. It relies on the effect

of an electric discharge in a liquid medium, which creates a cavitation bubble that

undergoes rapid expansion and contraction. This results in a shockwave that, when

transmitted to the stone, fragments it. Severe damage to the ureteral mucosa can be

caused by this lithotriptor, ranging from nonthermal perforation to extensive tissue

damage secondary to the cavitation bubble (223).

4. Holmium: Yttrium-Aluminum-Garnet Laser is the most recent technology available for

ureteral stone fragmentation. Laser devices rely on photothermal energy to fragment

stones. The laser fibers are available in a range of sizes, from 200 to 1000 microns, and

can be used through rigid and flexible endoscopes. To achieve optimal results and avoid

tissue damage, the fiber should be in direct contact with the stone at the time of activa-

tion. Reported stone fragmentation rates range from 90 to 100% (224,225). The depth

of tissue thermal injury with the Holmium: YAG ranges from 0.5 to 1 mm, and, because

of this, it is extremely important to maintain the distance between the ureteral tissue and

the probe tip greater than 1 mm (226). In practice, major soft tissue injuries with the

Holmium: YAG lithotripsy are rare because the tip of the probe has to be in direct contact

with the stone surface to be effective. Also, the low power settings required for litho-

tripsy are much lower than that used for tissue ablation. However, the Holmium: YAG

laser can cut through guidewires and stone baskets and must be guarded against this

occurrence.

Ureteral Injury

The rapid development of smaller and more efficient scopes has facilitated the use of

ureteroscopy for the treatment of ureteral calculi. Although these advances have de-

creased the need for open ureteral surgery, iatrogenic injury can still occur with the

endoscopic technique. Possible iatrogenic complications of ureteroscopy include ure-

teral perforation, stricture, false passage, ureteral avulsion, bleeding from the ureteral

mucosa or adjacent structures, infection, and sepsis. Several studies have reported the

overall complication rate associated with ureteroscopy to be between 1% and 15% (227–

230). These complication rates have steadily decreased over the years.

Grasso et al. (231) reported on the complication rate for his series of 560 patients who

underwent any type of ureteropyeloscopy. The reported incidence of pain, fever, false

passage, and urinary tract infection were 5.5%, 1.4%, 0.4%, and 1.6%, respectively.

Ureteral perforation usually occurs during placement of a guidewire, especially in cases

associated with long standing, impacted, obstructing ureteral stones. In cases in which the

regular safety wire cannot be advanced with ease, a retrograde pyelogram should be per-

formed to delineate the anatomy of the ureter and collecting system (Fig. 6). After the

retrograde is performed, a wire covered with hydrophilic polymer (Glidewire™) can

usually be advanced into the collecting system. If the ureter is tortuous, use of a 5-Fr open-

ended ureteral catheter along with a Bentson tip guidewire is recommended (232). Despite

these techniques, if advancing a wire is not possible, the renal unit should be drained

proximally with a nephrostomy tube.

Chapter 27 / Complications of Urinary Stone Surgery 537

If the area associated with the ureteral stone is long and fibrotic, consideration for

open or laparoscopic resection of the diseased segment should be made. Reconstruction

after the resection can be made with an end-to-end anastomosis, Boari flap, Psoas hitch,

transureteral–ureteral anastomosis, or ileal interposition, depending on the length and

location of the defect. Ureteral stricture after ureteroscopy can also be secondary to

ureteral perforation, submucosal false passage formation, or trauma of the ureteral wall

while performing stone fragmentation or manipulation. Usually a small perforation or

false passage, secondary to an incorrectly placed guidewire, will heal without serious

complications with time and adequate stent drainage. However, balloon dilation over a

perforating wire can convert a small perforation into a large laceration or avulsion. Major

ureteral perforations can also be caused by excessive force applied to a rigid ureteroscope,

especially over the iliac vessels. Another possible complication of ureteral tear could be

the migration of the stone or fragment through the mucosal tear and the formation of a

stone granuloma and subsequent ureteral stricture (233).

Complications During Stone Manipulation

It is important to avoid basketing of large stones and subsequent extraction without

fragmentation. It is obvious that a large stone that did not pass spontaneously would not

necessarily pass while basketing without applying undue amount of tension to the ureter

and the ureteropelvic junction. The most feared complication of this maneuver is the

complete avulsion of the ureter with eversion into the bladder. Usually this complication

will lead to a large ureteral defect and an even larger devascularized ureteral segment.

In such patients, immediate exploration with attempted re-anastomosis of the ureteral

ends is recommended. Failure to do so or failure in adequate healing because of devas-

cularization will lead to ileal replacement of the ureter, renal auto-transplantation, or

nephrectomy. Stone fragmentation and manipulation should be performed under direct

vision.

Complications to Adjacent Structures

Another important consideration while performing ureteroscopic procedures should

be avoiding trauma to adjacent vascular structures. This is especially important while

performing ablative procedures in the area of the iliac vessels or with UPJ procedures

in the presence of aberrant crossing vessels. Adequate preoperative imaging techniques

should identify any potential problems.

It is extremely important to identify minor problems during ureteroscopy to avoid

progression of the trauma. Adequate drainage of the kidney and aborting the procedure

are always safe and acceptable options when a complication is encountered. Patients

with postureteroscopy stent placement should be monitored and the stent removed

promptly to prevent risk of stent calcification (Fig. 7).

Conclusion

The formula for a low rate of complication during ureteroscopic procedures is appro-

priate instrumentation, adequate fluoroscopic imaging, avoiding improper application

of force to a rigid ureteroscope, placement of safety wire, avoiding advancement of

instrument without direct visual imaging, safe application of fragmentation techniques,

and knowing one’s limitations at the time of the procedure.

538 Urena, Mendez-Torres, and Thomas

COMPLICATIONS RELATED TO OPEN SURGERY

In the era of minimally invasive surgery, the use of open surgery to treat urolithiasis

has decreased dramatically. However, urologists should be proficient in these open

surgical techniques in case they come across challenges such as a large staghorn calculus

requiring intrarenal reconstruction of the collecting system or another stone not ame-

nable to treatment with minimally invasive techniques (Fig. 8).

Before 1880, renal stone surgery was performed only in obstructed, grossly infected

kidneys. At the time of perinephric abscess drainage, stones protruding from the kidney

were removed or left to drain through the incision or fistulous tract. Severe intrarenal

hemorrhage was the major complication associated with this procedure because of

the lack of knowledge of the intrarenal vascular distribution. In 1880, Morris (234)

described the first known nephrolithotomy in a nonabscessed kidney. Afterwards, he

performed 34 consecutive renal surgeries for removal of stones, reporting a recovery rate

of greater than 90%.

The later publication of The Intrinsic Blood Vessels of the Kidney and Their Signifi-

cance in Nephrotomy by Max Brodel (235) in 1901 described the ramifications of the

renal artery and the existence of an avascular plane between the anterior and posterior

arterial segments. The further development of radiological techniques, including intra-

operative X-rays and ultrasound, helped to further refine stone localization and make

open renal surgery more accurate and easier (236).

Open surgery today includes anatrophic nephrolithotomy, pyelolithotomy, radial

serial nephrotomies, ureterolithotomy, cystolithotomy, and urethrolithotomy. Compli-

cations for these surgeries can be divided into: (a) those associated with renal exposure

and (b) complications associated with surgical approach to the calculus. Herein, we

review the complications associated with these surgical procedures.

Fig. 7. Severely calcified and fragmented proximal curl of ureteral stent.

Chapter 27 / Complications of Urinary Stone Surgery 539

Complications of Incisions and Renal Exposure

Several different skin incisions can be performed to approach the kidney. The deci-

sion of the surgical technique to be used depends on the surgeon’s familiarity with

different incisions available and the location of the urinary tract needing surgical inter-

vention.

TANDARD FLANK INCISION

Standard flank incision, with or without rib resection, has been associated with

increased

postoperative pain and discomfort (because the muscles are incised), which

can result in decreased ambulation and increased requirements of pain medication.

Fig. 8. Large staghorn calculi involving all calyceal groups.

540 Urena, Mendez-Torres, and Thomas

Inadvertent surgical division of the intercostal nerves results in denervation of the

flank muscles, which can result in flank bulging after surgery not associated with true

hernias. Honig et al. (237) reported that up to 15% of patients with flank incisions would

develop flank bulges secondary to laxity of the flank muscles. Aside from denervation

injuries, nerve trauma, and entrapment, flank pain is another complication that can occur

after flank incisions. To avoid these complications, the intercostal nerve should be

identified and preserved during dissection, if at all possible.

Another uncommon complication associated with the flank incision could be the

formation of a flank hernia. Flank hernias are a rare problem and are more common in

extremely obese, immunocompromised, or malnourished patients. Extreme caution

should be taken during closure in these patients, and sometimes the use of internal

retention sutures is necessary. Flank hernias should always be repaired in patients who

are good surgical candidates, but, in severely debilitated patients with easily reducible

hernias, a more conservative treatment should be considered.

NTERIOR TRANSPERITONEAL APPROACH

A transperitoneal approach can be difficult in obese patients because of the depth of

the surgical field and because the panniculus and peritoneal contents can interfere with

adequate visualization of the retroperitoneum. Also, violation of the peritoneum pre-

disposes the patient to intestinal adhesion formation (238). The potential spillage of

infected urine into the peritoneal cavity with subsequent abscess and adhesion formation

is another drawback for the transperitoneal approach.

OSTERIOR APPROACHES

Posterior approaches can be used to gain access to the kidney and upper ureter in an

extraperitoneal manner. This lumbotomy approach is usually well tolerated with mini-

mal postoperative pain and early ambulation because few muscle groups are divided. The

major drawback of this incision is the lack of exposure to the renal vessels during surgery.

Thus, renal vein and artery control during iatrogenic vascular damage is extremely

difficult to obtain. Another disadvantage of this approach is the fact that the renal unit

moves anteriorly, away from the surgeon, during prone positioning of the patient.

NFECTION

There is a risk of wound infection in all skin incisions made for removal of urinary

calculi. It is important to treat any urinary tract infection before performing any proce-

dure for stone extraction, prompt identification of skin changes, and treatment with

appropriate antibiotics. Local wound care is crucial in the treatment of this complication.

One should identify high risk factors such as obesity and diabetes.

Pneumothorax

Pneumothorax is a complication associated not only with percutaneous renal access

but also with open renal surgery. Pneumothorax occurs in fewer than 5% of patients

undergoing open nephrolithotomy (239). This complication is more common in patients

with multiple previous renal surgeries and previous history of pyelonephritis or peri-

renal abscess. After damage to the diaphragm and pleura is identified, primary closure

with running absorbable suture can be performed after all the air is drained from the

pleura with a 14-Fr red rubber catheter placed in a bowl of sterile water during complete

Chapter 27 / Complications of Urinary Stone Surgery 541

expansion of the lungs by the anesthesiologist. Following this, a chest X-ray should be

performed to assess whether any residual pneumothorax is present. If present and clini-

cally significant, a chest tube should be inserted for at least 48 h and managed in a routine

manner.

Complications Associated With Calculus Extraction

HEMORRHAGE

As with any surgical procedure, excessive bleeding is a possibility that has to be

addressed. Although hemorrhage from the kidney during pyelolithotomy or nephroli-

thotomy is usually avoidable with good surgical techniques and gentle tissue handling,

bleeding during an anatrophic or peripheral nephrolithotomy was seen in up to 10% of

patients in Spirnak’s reported series (240). To avoid this, control of the renal artery and

vein should be obtained before incising the renal parenchyma. After vascular control is

obtained, the renal incision should be obtained in the avascular plane of the kidney

situated about 1 cm posterior to Brodel’s white line. Intravenous injection of methylene

blue can be used to demarcate the avascular plane. Any bleeding sites encountered

during dissection should be closed using 3-0 absorbable sutures.

Postoperative bleeding usually results from inadequately controlled intrarenal ves-

sels. Bed rest, IV fluids, and, if needed, blood transfusion will usually control the bleed-

ing. If patients develop hemodynamic instability and cannot be managed medically,

angiography and super-selective embolization should be performed. Re-exploration

should be reserved for patients who fail embolization because of the higher incidence of

renal loss.

DJACENT ORGAN TRAUMA

Trauma to adjacent organs can occur, especially in infected or severely reactive renal

units. While operating on the right kidney, attention should be paid on the duodenum,

head of the pancreas, liver, short right adrenal vein, the inferior vena cava, and ascending

colon. Inadvertent trauma to these structures can occur during blunt or sharp dissection

or retractor placement.

On the left side, adjacent structures prone to damage include descending colon, the tail

of the pancreas, and spleen. Conservative vs surgical management of trauma to adjacent

organs is dependent on the degree of trauma, time elapsed before diagnosis, and clinical

condition of the patient.

ETAINED STONE FRAGMENTS AND STONE MIGRATION

Intrarenal migration of calculi during open exploration and manipulation of the kid-

ney is a common and serious problem. It is extremely important to obtain distal ureteral

control with a vessel loop before making an incision in the renal pelvis. This maneuver

will prevent distal migration of the stone while manipulating the kidney. The incision in

the renal pelvis should be performed exactly over the stone after direct palpation. It is

also important to make the incision away from the uretero-pelvic junction to avoid

transection of this area and possible subsequent stricture formation.

If in doubt of the exact position of the renal stone, intraoperative X-ray should be taken

to asses the exact position of the stone before performing the incision. When a large

pelvis or ureteral incision is made or when some small fragments may have migrated,

intraoperative placement of an indwelling ureteral stent is recommended to protect the

closure and to avoid acute renal obstruction from distally migrated stone fragments.

542 Urena, Mendez-Torres, and Thomas

Inadvertent retention of stone fragments after open renal surgery is a common occur-

rence with reported incidence of up to 30% (239). It is important to obtain intraoperative

X-rays to compare them to preoperative studies and assess residual stones. For stones

that are not reachable through the already-made pyelotomy, a flexible cystoscope/nephro-

scope can be used to gain access and remove these calculi. Fragmentation with Hol-

mium: YAG laser or intact basketing are two possible ways of treating these hard-to-reach

fragments. Postoperative SWL is another possible alternative to treat small-retained

fragments in a nonoccluded system.

RINARY LEAKAGE

Persistent urinary leakage and urinary fistula formation, either pyelocutaneous,

nephrocutaneus or ureterocutaneous, are problems that can be encountered after open

surgery for renal stones. These complications are usually associated with distal obstruc-

tion, infection, and foreign bodies in the urinary system or devascularization of tissue

secondary to surgical dissection. After these problems are diagnosed, adequate renal

drainage with either indwelling ureteral stent or nephrostomy tube and indwelling blad-

der Foley catheter placement are usually enough to control the leakage. The majority of

these extravasations resolves with adequate drainage (Fig. 9).

Fig. 9. Closed suction drain showing moderate extravasation of contrast material from the lower

calyceal group after open renal surgery.

Chapter 27 / Complications of Urinary Stone Surgery 543

When the urinary leakage cannot drain to the exterior, a urinoma can form. To treat

this, adequate drainage of the kidney is also necessary, and percutaneous drainage of the

urinoma collection should be performed to avoid further complications such as abscess

formation. To confirm the nature of the fluid collection, creatinine levels should be tested

on the drained fluid and compared to serum levels.

Urinary leakage can be avoided with meticulous, watertight closure of the collecting

system or ureter without tension. The use of 3-0 absorbable sutures in a continuous or

interrupted manner is adequate for this purpose. Formation of large flaps of tissue

should be avoided during dissection, and adequate drainage of the renal unit should be

procured. In cases in which the leakage cannot be controlled with stents or nephrostomy

tubes, re-exploration with resection of the diseased segment and reconstruction should

be performed, following standard and time-tested urologic principles.

CONCLUSION

In conclusion, with a variety of options available for the treatment of symptomatic

urolithiasis, a sound understanding of the principles of choosing a treatment option is

essential. Potential complications should be known so that urologists can take every

measure to prevent one.

REFERENCES

1. Chaussy C, Brendel W, Schmiedt E. Extracorporeally induced destruction of kidney stones by

shockwaves. Lancet 1980; 13(2):1265–1268.

2. Chaussy C, Schmiedt E, Jocham D, Brendel W, Forssmann B, Walther V. First clinical experience

with extracorporeally induced destruction of kidney stones by shockwaves. J Urol 1982; 127: 417–

420.

3. Chaussy CG. ESWL: past, present and future. J Endourol 1988; 2: 97–105.

4. Krings F, Tuerk CH, Steinkogler I, Marberger M. Extracorporeal shock-wave lithotripsy treatment

(“stir-up”) promotes discharge of persistent calyceal stone fragments after primary extracorporeal

shockwave lithotripsy. J Urol 1992; 148: 1040–1042.

5. Wickham JEA. Treatment of urinary tract stones. Br Med J 1993; 307: 1414–1417.

6. Grasso M, Loisides P, Beaghler M, Bagley D. The case for primary endoscopic management of

upper urinary tract calculi: a critical review of 121 extracorporeal shock-wave lithotripsy failures.

Urology 1995; 45: 363–371.

7. Chaussy C, Schmiedt E, Jocham D, Brendel W, Forssmann, Walther V. First clinical experience

with extracorporeally induced destruction of kidney stones by shock waves. J Urol. 1982; 127(3):

417–420.

8. Lingeman JE, Lifshitz DA, Evan AP. Surgical management of urinary lithiasis. In: Campbell’s

Urology, 8th Ed., (Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds.). Penn, Philadelphia, PA,

2002, pp. 3361–3451.

9. Zhong P, Preminger GM. Mechanisms of differing stone fragility in extracorporeal shockwave

lithotripsy. J Endourol 1994; 8: 263–268.

10. Saw KC, McAteer JA, Fineberg NS, et al. Calcium stone fragility is predicted by helical CT

attenuation values. J Endourol 2000; 14: 465–468.

11. Saw KC, McAteer JA, Monga AG, Chua GT, Lingeman JE, Williams JC Jr. Helical CT of urinary

calculi: effect of stone composition, stone size, and scan collimation. AJR Am J Roentgenol 2000;

175: 329–332.

12. Pittomvils G, Vandeursen H, Wevers M, et al. The influence of internal stone structure upon the

fracture behavior of urinary calculi. Ultrasound Med Biol 1994; 20: 803–810.

13. Saw KC, Lingeman JE. Lesson 20—management of calyceal stones. AUA Update Series 1999; 20:

154–159.

14. Dretler SP: Stone fragility. A new therapeutic distinction. J Urol 1988; 139: 1124–1127.

544 Urena, Mendez-Torres, and Thomas

15. Motola JA, Smith AD. Therapeutic options for the management of upper tract calculi. Urol Clin

North Am 1990; 17: 191–206.

16. Chaussy C, Schuller J, Schmiedt E, Brandl H, Jocham D, Liedl B. Extracorporeal shockwave

lithotripsy (ESWL) for treatment of urolithiasis. Urology 1984; 23: 59–66.

17. Lingeman JE. Percutaneous procedures. In: Urinary Calculi, (Lingeman JE, Smith LH, Woods JR,

Newman DM, eds.). Lea & Febiger, Philadelphia, PA, 1989, pp. 322–359.

18. Psihramis KE, Jewett MA, Bombardier C, Caron D, Ryan M. Lithostar extracorporeal shockwave

lithotripsy: the first 1,000 patients. J Urol 1992; 147: 1006–1009.

19. Lingeman JE, Siegel YI, Steele B, Nyhuis AW, Woods JR. Management of lower pole nephroli-

thiasis: A critical analysis. J Urol 1994; 151: 663–667.

20. Cass AS. Comparison of first generation (Dornier HM-3) and second generation (Medstone STS)

lithotriptors: Treatment results with 13,864 renal and ureteral calculi. J Urol 1995; 153: 588–592.

21. Murray MJ, Chandhoke PS, Berman CJ, Sankey NE. Outcome of extracorporeal shockwave

lithotripsy monotherapy for large renal calculi. Effect of stone and collecting system surface areas

and cost-effectiveness of treatment. J Endourol 1995; 9: 9–13.

22. Logarakis NF, Jewett MAS, Luymes J, Honey RJ. Variation in clinical outcome following

shockwave lithotripsy. J Urol 2000; 163: 721–725.

23. Renner CH, Rassweiler J.: Treatment of renal stones by extracorporeal shockwave lithotripsy.

Nephron 1999; 81: 71–81.

24. Albala DM, Assimos DG, Clayman RV, et al. Lower Pole I: a prospective randomized trial of

extracorporeal shockwave lithotripsy and percutaneous nephrostolithotomy for lower pole neph-

rolithiasis-initial results. J Urol 2001; 166(6): 2072–2080.

25. Swanson SK. Excretory urography during extracorporeal shock-wave lithotripsy: a location alter-

native. Urology 1992; 39: 185–186.

26. Sundaram CP, Saltzman B. An effective technique to facilitate radiographic stone visualization

with an internal stent during shockwave lithotripsy. J Urol 1998; 160(4): 1414, 1415.

27. Thomas R, Cass AS. Extracorporeal shockwave lithotripsy in morbidly obese patients. J Urol

1993; 150: 30–32.

28. Hoffmann R, Stoller ML. Endoscopic and open stone surgery in morbidly obese patients. J Urol

1992; 148: 1108–1111.

29. Thomas R, Macaluso JN, Vandenberg T, Salvatore F. An innovative approach to management of

lower third ureteral calculi. J Urol 1993; 149: 1427–1430.

30. Drach GW, Dretler S, Fair W, et al. Report of the United States cooperative study of extracorporeal

shockwave lithotripsy. J Urol 1986; 135: 1127–1133.

31. Graff J, Deidrichs W, Schultz H. Long-term follow-up in 1,003 extracorporeal shockwave litho-

tripsy patients. J Urol 1988; 140: 479.

32. Kohrmann KU, Rassweiler J, Alken P. The recurrence rate of stones following ESWL. World J

Urol 1993; 11: 26–30.

33. Streem SB, Yost A, Mascha E. Clinical implications of clinically insignificant stone fragments

after extracorporeal shockwave lithotripsy. J Urol 1996; 155: 1186–1190.

34. Newman DM, Scott JW, Lingeman JE. Two year follow up of patients treated with extracorporeal

shockwave lithotripsy. J Endourol 1988; 2: 163–171.

35. Zanetti G, Seveso M, Montanari E, Guarneri A, Del Nero A, Nespoli R, Trinchieri A. Renal stone

fragments following shockwave lithotripsy. J Urol 1997; 158: 352–355.

36. Candau C, Saussine C, Lang H, Roy C, Faure F, Jacqmin D. Natural history of residual renal stone

fragments after ESWL. Eur Urol 2000; 37: 18–22.

37. Nijman RJ, Ackaert K, Scholtmeijer RJ, Lock TW, Schroder FH. Long-term results of extracor-

poreal shockwave lithotripsy in children. J Urol 1989; 142: 609–611.

38. Beck EM, Riehle RA. The fate of residual fragments after extracorporeal shockwave lithotripsy

monotherapy of infection stones. J Urol 1991; 145: 6.

39. Fuchs AM, Wolfson BA, Fuchs GJ. Staghorn stone treatment with extracorporeal shockwave

lithotripsy monotherapy: Long-term results. J Endourol 1991; 5: 45.

40. Nakamoto T, Sagami K, Yamasaki A, et al. Long-term results of endourologic treatment of

urinary calculi: investigation of risk factors for recurrence or re-growth. J Endourol 1993; 7:

297–301.

Chapter 27 / Complications of Urinary Stone Surgery 545

41. Conlin MJ. Complications of extracorporeal shock-wave lithotripsy. In: Complications of Uro-

logic Surgery, Prevention and Management, 3rd Ed., (Taneja SS, Smith RB, Ehrlich RM, eds.).

WB Saunders, Philadelphia, PA, 2001, pp. 155–164.

42. McCullough, DL. Extracorporeal shock-wave lithotripsy. In: Campbell’s Urology, vol. I, (Walsh

PC, Retik AB, Stamey TA, et al., eds.). WB Saunders, Philadelphia, PA, 1992, pp. 2157–2182.

43. Sulaiman MN, Buchholz NP, Clark PB. The role of ureteral stent placement in the prevention of

Steinstrasse. J Endourol 1999; 13(3): 151–155.

44. Sayed MA, el-Taher AM, Aboul-Ella HA, Shaker SE. Steinstrasse after extracorporeal shock-

wave lithotripsy: aetiology, prevention and management. Br J Urol 2001; 88: 675–678.

45. 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:

1239–1242.

46. Fedullo LM, Pollack HM, Banner MP, Amendola MA, Van Arsdalen KN. The development of

steinstrassen after ESWL: frequency, natural history, and radiologic management. Am J Roentgenol

1988; 151: 1145–1147.

47. Fine H, Gordon RL, Lebensart PD. Extracorporeal shock-wave lithotripsy and stents: Fluoroscopic

observations and a hypothesis on the mechanism of stent function. Urol Radiol 1989; 11: 37.

48. Ramsay JW, Crocker RP, Ball AJ, Jones S, Payne SR, Levison DA, Whitfield HN. Urothelial

reaction to ureteric intubation: a clinical study. Br J Urol 1987; 60: 504, 505.

49. Saltzman, B. Ureteral stents indications, variations and complications. Urol Clin North Am 1988;

15: 481.

50. Bregg K, Riehle RA Jr. Morbidity associated with indwelling internal ureteral stents after

shockwave lithotripsy. J Urol 1989; 141: 510–512.

51. Preminger GM, Kettelhut MC, Elkins SL, Seger J, Fetner CD. Ureteral stenting during extracor-

poreal shockwave lithotripsy: help or hindrance? J Urol 1989; 142: 32–36.

52. Low RK, Stoller ML, Irby P, Keeler L, Elhilali M. Outcome assessment of double-J stents during

extracorporeal shockwave lithotripsy of small solitary renal calculi. J Endourol 1996; 10: 341–

343.

53. Al-Awadi KA, Abdul Halim H, Kehinde EO, Al-Tawheed A. Steinstrasse: a comparison of inci-

dence with and without J stenting and the effect of J stenting on subsequent management. Br J Urol

1999; 84: 618–621.

54. Hollowell CM, Patel RV, Bales GT, Gerber GS. Internet and postal survey of endourologic prac-

tice patterns among American urologists. J Urol 2000; 163: 1779–1782.

55. Chandhoke PS, Barqawi AZ, Wernecke C, Chee-Awai RA. A randomized outcomes trial of ure-

teral stents for extracorporeal shockwave lithotripsy of solitary kidney or proximal ureteral stones.

J Urol 2002; 167: 1981–1983.

56. Kim SC, Oh CH, Moon YT, Kim KD. Treatment of steinstrasse with repeated extracorporeal

shockwave lithotripsy: experience with piezoelectric lithotriptor. J Urol 1991; 145: 489–491.

57. Coptcoat MJ. The Steinstrasse: classification and management. In: Lithotripsy II. (Coptcoat MJ,

Miller RA, Wickham JEA, eds.) BDI, London, 1987, pp. 133–137.

58. Coptcoat MJ, Webb DR, Kellet MJ, Whitfield HN, Wickham JE: The Steinstrasse: a legacy of

extracorporeal lithotripsy. Eur Urol. 1988; 14(2): 93–95.

59. Newmark JR, Wong MYC, Lingeman JE. Complications. In: Smith’s Textbook of Endourology,

vol, I., (Smith AD, Bagley DH, Clayman RV, et al., eds.). Quality Medical, St. Louis, MO, 1996,

pp. 680–693.

60. Weinerth JL, Flatt JA, Carson CC: Lessons learned in patients with large Steinstrasse. J Urol 1989;

142: 1425–1427.

61. Sigman M, Laudone V, Jenkins AD. Ureteral meatotomy as a treatment of Steinstrasse following

extracorporeal shockwave lithotripsy. J Endourol 1988; 2: 41.

62. Rubenstein MA, Norris DM. Variation on water-pik technique for treatment of steinstrasse after

ESWL. Urology 1988; 32: 429–430.

63. Clayman RV. Incidence of urinary tract infection in patients without bacteriuria undergoing SWL:

comparison of stone types. J Urol 1999; 161: 727, 728.

64. Dincel C, Ozdiler E, Ozenci H, Tazici N, Kosar A. Incidence of urinary tract infection in patients

without bacteriuria undergoing SWL: comparison of stone types. J Endourol 1998; 12: 1–3