title: Steinstrasse: a comparison of incidence with and without J stenting and the effect of J stenting on subsequent management.
abstract: OBJECTIVE
  To analyse the effect of ureteric stenting on the incidence of steinstrasse and its effects on the subsequent management of steinstrasse.
  
  
  METHODS
  Four hundred adult patients with a unilateral stone burden (mean diameter 1.5-3.5 cm) were randomly allocated into two groups; in group 1, patients had a J stent inserted before extracorporeal shock wave lithotripsy (ESWL) and group 2 did not. Before randomization, the patients had normal renal function and no evidence of ureteric obstruction on intravenous urography. All patients underwent ESWL, with the shock waves delivered first to the most dependent part of the calculi. Patients who developed steinstrasse were identified and the effect of the size of the calculi and the presence of a J stent on the incidence and level of the steinstrasse, on the time of diagnosis, the size of the major stone fragment, associated presenting symptoms and effect on subsequent management were compared between the groups.
  
  
  RESULTS
  Patients developed steinstrasse in both groups, with 12 (6%) and 26 (13%) in groups 1 and 2, respectively (significantly different, P<0.05). The incidence of steinstrasse depended on the size of the calculus, regardless of whether a J stent was present, being 2.6% and 56% for a burden of 1.5-2.0 cm and 3.1-3.5 cm, respectively (P<0.001). There was no difference in the presenting symptoms in the two groups. The steinstrasse was in the lower third of the ureter in eight of 12 patients in group 1 and in 16 of 26 (62%) in group 2. The steinstrasse resolved spontaneously in seven patients in group 1 and in 12 (46%) in group 2 (P<0.11). Similarly, J stenting had no effect on the subsequent treatment modalities to resolve steinstrasse.
  
  
  CONCLUSIONS
  The use of J stenting before lithotripsy significantly lowers the incidence of steinstrasse in patients with a stone burden of 1.5-3.5 cm. The incidence of steinstrasse increases with the size of the calculi, whether or not a J stent is present; J stenting has no apparent effect on the mode of presentation or the subsequent management of steinstrasse.
authors.affiliation: Department of Urology, Mubarak Al-Kabeer Hospital and Department of Surgery, Kuwait University, Kuwait.
authors.forename: K A
authors.initials: KA
authors.lastname: Al-Awadi
authors.forename: H
authors.initials: H
authors.lastname: Abdul Halim
authors.forename: E O
authors.initials: EO
authors.lastname: Kehinde
authors.forename: A
authors.initials: A
authors.lastname: Al-Tawheed
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D008096:Lithotripsy / Q000379:methods*; D008297:Male; D015607:Stents; D016896:Treatment Outcome; D014517:Ureteral Obstruction / Q000517:prevention & control*; D014545:Urinary Calculi / Q000628:therapy*