Does the type of steinstrasse predict the outcome of expectant therapy?

OBJECTIVES: To determine the outcome of expectant therapy in steinstrasse according to its type. MATERIALS AND METHODS: A chart review was performed on patients who underwent extracorporeal shock wave lithotripsy (SWL) between 1995 and June 2004. Demographic profile, stone size, site, characteristics of steinstrasse (type 1; multiple small fragments, type 2; lead fragment of 5 mm or more with small fragments proximal to it and type 3; multiple fragments of 5 mm or more) and mode of treatment used, were noted. Patients of steinstrasse, diagnosed on X-Ray KUB were kept on expectant treatment for 4 weeks. Patients with high grade fever and infected hydronephrosis were treated with percutaneous nephrostomy (PCN) insertion. Non responders at 4 weeks, were treated with SWL and/or ureterorenoscopy (URS). RESULTS: 1000 patients of mean age 37.85 years, with urinary stones, received SWL (827 renal stones and 173 ureteric stones). Sixty patients (6%) developed steinstrasse. Mean stone size was 2.03 cm (0.6-4 cm). Type 1, 2 and 3 steinstrasse was present in 32 (53%), 20 (33%) and 8 (13%) patients, respectively. Conservative management was successful in 30 (50%) patients at 4 weeks. 3 patients who presented with infected hydronephrosis, required PCN. The remaining (27 patients) were subjected to repeat SWL. 24 of these 27 patients could be successfully treated with SWL, whereas the remaining 3 required URS. Of non- responders to conservative treatment i.e., 30 patients, 17 (56%) and 8 (26%) patients had type 2 and 3 steinstrasse respectively, whereas only 3 out of 30 (10%) responders had type 2 and none of the responders had type 3 steinstrasse, P value < 0.01. CONCLUSION: Type 2 and 3 steinstrasse have 90% (25 out of 28 failed) chance of not responding to the conservative treatment at 4 weeks. To avoid the risk of infected hydronephrosis (5%), active intervention should be done in patients with lead fragment of 5 mm or more (type 2 and 3 steinstrasse), as early as possible. SWL is successful in most of these patients and should be the primary modality of treatment

Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach

Purpose: We aim to present our experience for the repair of vesicovaginal fistula (VVF) with special reference to surgical approach. Materials and Methods: From January 1999 to June 2005, 52 VVF patients with mean age of 32 years underwent operative treatment. Fistulas were divided into two groups, simple and complex, depending on site, size, etiology and associated anomalies. Simple VVFs were approached through the vaginal route and complex VVFs via the transabdominal route. Patients were evaluated at two to three weeks initially, three-monthly twice and later depending on symptoms. Results: Thirty-two (61.5%) had simple fistulas and 20 (38.5%) complex fistulas. The most common etiology was obstetric trauma in 31 (59.6%) patients, while the second most common cause was post hysterectomy VVF. Thirty-two (61.5%) patients were managed by transvaginal route, of which 17 had supratrigonal and 15 trigonal fistulas. Twenty (38.5%) patients with complex fistulas were managed by abdominal route. The mean blood loss, postoperative pain and mean hospital stay were shorter in transvaginal repair. Eleven (21.2%) patients required ancillary procedures for various other associated anomalies at the time of fistula repair. Three patients failed repair giving a success rate of 94.2%. At a mean follow-up of three years 48 women were sexually active, of these 10 (19.2%) complained of mild to moderate dyspareunia. Conclusion: Most of the simple fistulas irrespective their locations are easily accessible transvaginally while in complex fistulas we recommend the transabdominal approach. Depending on the clinical context both the approaches achieved comparable success rates