Management of Complications Following Extracorporeal Shock Wave Lithotripsy: Steinstrasse

Abstract

ESWL disintegrates human urinary stones contained in the upper urinary tract noninvasively. After successful disintegration, the resulting stone gravel is then eliminated spontaneously with the urine from the upper urinary tract.

The incidence of postprocedural complications during the elimination of gravel and the length of time needed for elimination are directly related to the initial stone mass. Stones less than 2.5 cm require invasive auxiliary procedures (percutaneous nephrostomy, ureteroscopy) after ESWL in approximately 10% of patients, whereas in larger stones auxiliary procedures are needed in up to 60% of patients.

The most common complication after ESWL treatment is ureteral steinstrasse which presents as ureteral obstruction and hydronephrosis caused by passing debris. On ultrasound, this condition can be detected at some point during the follow-up in approximately 60% of all stone patients. With smaller stones usually no therapy is necessary and the steinstrasse resolves within days without any clinical symptoms other than occasional pain.

In cases of prolonged obstruction where obstructive pyelonephritis (5%) may occur, percutaneous drainage is required. Longstanding obstruction without symptoms (2%) needs to be relieved as well.

Ureteroscopy is performed less frequently (3%) since the liberal use of nephrostomy tube drainage allows for spontaneous passage of the gravel in most instances. As a rule, increasing stone size leads to an increased risk of complications such as pain, obstructive pyelonephritis, and urosepsis. Therefore, patients with residual stone debris need to be followed with special diligence until they are free of stone material.