e-ISSN:2148-1547
Şok Dalga Litotripsisi Sonrası Gelişen Masif Taş Yolu
Massive Stone-street After Shock Wave Lithotripsy
Olgu Sunumu
Başvuru: 11.11.2014
Kabul: 01.12.2014
Yayın: 05.12.2014
Ekrem Akdeniz1, Mustafa Suat Bolat1, Necmettin Şahinkaya1, Acun Saylık1, Mevlüt Keleş1
1
Samsun Eğitim ve Araştırma Hastanesi Üroloji Kliniği
Özet
Abstract
Taşyolu üreterde idrar geçişine izin vermeyen taş
birikimidir. Genellikle taş hacmi fazla olan Şok Dalga
Litotripsisi (ŞDL) sonrası gelişir. Standart bir tedavi
protokolü yoktur. Bu çalışmamız da ŞDL sonrası
proksimal üreterde masif taşyolu gelişen ve
Üreterorenoskopi (URS) ile tedavi edilen olgu
tartışılmıştır.
Stone-street is an accumulation of stone fragments in
the ureter allows no urine passage. It usually develops
after Shock Wave Lithotripsy (SWL) of huge volume
of stones. There is no standard therapy protocol. In
this study, we discussed development of stone-street
in the proximal ureter after SWL and it\'s therapy
using Ureterorenoscope (URS).
Anahtar kelimeler: Şok Dalga Litotripsi, Taş yolu
Keywords: Shock Wave Lithotripsy, Stone-street
Introduction
Urolithiasis is a common clinical problem. At the beginning of 1980s, treatment of urolithiasis has changed
dramatically in favor of SWL by using lithotripsy. With minimally invasiveness and low complication rates, it
has almost been the first therapotic choice of urinary sistem stones. When compared with surgical methods, SWL
has very low complication rates [1]. Fragments of stone usually pass into bladder after SWL. If these fragments
block urine flow by stacking in the ureter, stone-street occurs [2]. Stone-street incidence is 4-7%. In this study,
development of massive stone street and its treatment with URS by using intracorporeal pneumatic lithotriptor
are discussed in the proximal ureter after SWL.
Case Report
Fifty-five years old male patient with hematuria and right side flank pain admitted to our clinic. Direct urinary
system plain graphy and non-contrast Computerized Tomograph (CT) were made (Figure 1). A radioopaque
stone, 267 mm² surface area was observed. There was no bacterial proliferation in urine and serum creatinine
level was 0,8 mg/dL. Patient was scheduled for SWL and in one session 4000 shock wave with 12 KW energy
was applied. After one week of SWL, patient admitted to emergency service with renal colic pain. Massive stone
street was seen in right ureter on plain radiography (Figure 1). Ureterorenoscopy is planned because of analgesic
resistant pain. The most distal part of stone was fragmented by using pneumatic lithotriptor. After this manouver
with irrigation, remaining proximally located stone fragments passed into the bladder spontaneously. A double J
stent was inserted and patient was discharged in post-operative first day after plain graphy is obtained (Figure 1).
Sorumlu Yazar: Ekrem Akdeniz, Samsun Eğitim ve Araştırma Hastanesi Üroloji Kliniği
Samsun Eğitim ve Araştırma Hastanesi Üroloji Kliniği
[email protected]
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Figure 1
Radiological Findings of Patient. a: Before SWL CT b: Before SWL Plain graphy c: Stone-street d:Control Plain
graphy after URS. (URS: Ureterorenoscopy CT: Computerized Tomography)
Discussion
Stone-street incidence is seen 4-7% after SWL for stones. The most important risc factor is stone burden [2].
Although SWL reduces stone-street incidence for stones which is greater than fifteen milimeter, does not
eliminate it completely. Whether or not DJ stent is inserted, as stone size increases more likely stone-street occurs
[4]
.
Stone-street often occupies part of the ureter but seldom entirely. More than 74% is seen in distal part of ureter [5].
Stone-street is located in proximal ureter in our patient and he presented medication resistant colic pain.
Stone-street may cause clinical symptoms such as flank pain, vomiting, nausea and bladder irritation but also may
be asymptomatic. The most important issue is ureteral obstruction that may reveals no clinical sign in 23% of
patients. In solitary kidney patients, anuria is seen 5% [5].
There is no standard therapotic option for stone-street. In asymptomatic patients, first choice is conservative
treatment. Medical treatment reduces rate of surgical intervention while increasing the rate of spontaneous stone
passage [6].
In symptomatic patients SWL, percutaneous nephrostomy, ureteral stent, URS are alternative treatment options.
URS and SWL must be the first option, in presence of big size of fragmented stone and no urinary infection. Both
URS and SWL success rates are equal. If patient reveals fever or urinary tract infection, percutaneous
nephrostomy should be applied. If SWL and other therapotical approaches fail, URS must be the firt option [1].
URS was performed in our patient because of the lack of urinary tract infection and analgesic resistant renal colic.
After the most distal part of stone was fragmented with pneumatic lithotriptor, proximally located other parts of
fragments passed into bladder spontaneously. Because patient will continue SWL, a double J stent was inserted
into the ureter. During procedure, any complication was seen.
As a result, stone street is an important clinical condition, may cause loss of renal function. Although it
frequently occurs after SWL, it should be kept in mind that it may occurs spontaneously. There is no standard
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therapotic protocol and the patient's preference must be considered during treatment planning.
References
1. Türk C, Knoll T, Petrik A, Sarica K, Skolarikos A, Straub M, Seitz C. EAU Guidelines on Urolithiasis.
European Association of Urology 2014.
2. Lucio J 2nd, Korkes F, Lopes-Neto AC, et al. Steinstrasse predictive factors and outcomes after
extracorporeal shockwave lithotripsy. Int Braz J Urol 2011 Jul-Aug;37(4):477-82.
3. Tolley DA. Consensus of lithotriptor terminology. World J Urol. 1993;11(1):37-42.
4. Soyupek S, Armagan A, Kosar A, et al. Risk factors for the formation of a steinstrasse after shock wave
lithotripsy. Urol Int. 2005;74:323-5.
5. Madbouly K, Sheir KZ, Elsobky E, et al. Risk factors for the formation of a steinstrasse after
extracorporeal shock wave lithotripsy: a statistical model. J Urol 2002 Mar;167(3):1239-42.
6. Moursy E, Gamal WM, Abuzeid A. Tamsulosin as an expulsive therapy for steinstrasse after
extracorporeal shock wave lithotripsy: a randomized controlled study. Scand J Urol Nephrol 2010
Nov;44(5):315-9.
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