Ureteral Meatotomy as a Treatment of Steinstrasse Following Extracorporeal Shock Wave Lithotripsy

Sixteen per cent of the first 1,053 patients who were treated with extracorporeal shock wave lithotripsy (ESWL) at the University of Virginia required some type of post-ESWL ancillary procedure. Obstructive Steinstrasse was initially managed with ureteral meatotomy in 50 patients, 18 of whom were evaluated with voiding cystourethrography at least 2 months later. One-third of these patients had more than a 50% reduction in the length of the Steinstrasse, but more than half had vesicoureteral reflux on follow-up cystogram that was low grade (grade I or II) in all but one patient (grade III). Ureteral meatotomy is best used for the removal of a large leading fragment that is impacted in the ureteral orifice. Impacted sand without any large fragments can be managed with pulsed water irrigation through an end-hole catheter or with percutaneous renal drainage. A percutaneous nephrostomy protects the kidney and seems to increase the efficiency of ureteral peristalsis and the expulsion of particles.