Proximal ureteral stone treatment requires multiple procedures until complete stone-free status is achieved. Laparoscopic ureterolithotomy is associated with higher success rates and fewer surgical procedures, but with more postoperative pain, longer procedures and a longer hospital stay. Although it is associated with the highest success rates for large proximal ureteral calculi, laparoscopic ureterolithotomy remains a salvage, second line procedure, and it seems more advantageous than open ureterolithotomy. At less well equipped centers, where semirigid ureterolithotripsy or extracorporeal shock wave lithotripsy is not available, it remains a good treatment option.

Purpose: Urinary stone disease is a common medical problem. Extracorporeal shockwave lithotripsy (SWL) has been applied with high success and low complication rates. Steinstrasse (SS) is a possible complication after SWL. The aim of the present study was to prospectively evaluate the factors and outcomes associated with SS after SWL. Materials and Methods:We have prospectively evaluated 265 SWL sessions (2005265 SWL sessions ( -2009. Two lithotriptors were used randomly: Siemens Lithostar and Dornier Compact S. All patients had imaging exams after 30 and 90 days or according to symptoms. Results: SS was observed in 14 (5.3%) out of 265 SWL procedures (n = 175 patients, 51.5% women/48.5% men, mean ± SD age = 46.3 ± 15.5 years). SS was more common after SWL for pelviureteral calculi rather than caliceal stones (p = 0.036). There was a trend toward more occurrences of SS after SWL for larger stone area (> 200 mm 2 , p = 0.072). Preoperative ureteral stent didn't prevent SS. SWL machine, intensity, number of pulses and frequency were not associated with SS formation. Post-SWL pain, fever and gravel elimination were factors associated with SS (p = 0.021; p = 0.011; p = 0.078). When SS occurred, treatment modalities included Medical Expulsive Therapy (MET), ureteroscopy and SWL. Conclusions: Steinstrasse is an uncommon event after SWL and seems to occur more frequently with larger pelviureteral stones. Impaction of stones is more frequent in the middle ureter. All patients should be followed after SWL, but SS should be specially suspected if there is macroscopic gravel elimination, flank pain and/or fever. When SS occurs, treatment should be promptly introduced, including medical expulsive therapy, surgical approach or SWL in selected cases. Further prospective studies are awaited to evaluated preventive measures for SS occurrence.

Introduction: Two positions have been reported for ureteroscopy (URS): dorsal lithotomy (DL) position and dorsal lithotomy position with same side leg slightly extended (DLEL). The aim of the present study was to compare the outcomes associated with URS performed with patients in DL vs. DLEL position. Materials and Methods: A total of 98 patients treated for ureteral calculi were randomized to either DL or DLEL position during URS, and were prospectively followed. Patients, stone characteristics and operative outcomes were evaluated. Results: Of the 98 patients included in the study, 56.1% were men and 43.9% women with a mean age of 42.6 ± 16.8 years. Forty-eight patients underwent URS in DL position and 50 in DLEL position. Patients' age, mean stone size and location were similar between both groups. Operative time was longer for the DL vs. DLEL group (81.0 vs. 62.0 minutes, p = 0.045), mainly for men (95.2 vs. 63.9 minutes, p = 0.023). Mean fluoroscopy use, complications and success rates were similar between both groups. Conclusions: Most factors associated with operative outcomes during URS are inherent to patient's condition or devices available at each center, and therefore cannot be changed. However, leg position is a simple factor that can easily be changed, and directly affects operative time during URS. Even though success and complication rates are not related to position, placing the patient in dorsal lithotomy position with an extended leg seems to make the surgery easier and faster.

We describe the case of a female patient with calcification in renal topography, initially diagnosed as lithiasis in the left kidney, and later attributed to calcification of intrarenal vascular aneurysm. Next, we discuss the relevance of considering such an entity in the differential diagnoses of intrarenal calcifications before choosing any form of specific interventional treatment.

The concept that extracorporeal shock wave lithotripsy (ESWL) may be used to successfully fragment urinary calculi in a noninvasive manner has revolutionized the management of urolithiasis.1 Complications of this procedure are usually limited to the kidneys and almost always resolve spontaneously.2 Whereas subcapsular renal hematomas have been present in up to 15% of patients in radiological studies, 3 hepatic hematomas have been reported only anecdotally and, to our knowledge, no case of infected hepatic hematoma has been previously described. The authors report a case of a patient who had an infected hepatic hematoma as a late complication of ESWL.A 35-year-old woman presented with a 1-year history of recurrent right renal colic and episodic macroscopic hematuria. The patient's medical history was unremarkable, and she was taking no medication. Physical examination disclosed an apparently healthy patient with no abnormality, with arterial blood pressure of 115/70 mm Hg. A plain radiograph of the abdomen, an ultrasound examination, and an excretory urogram (IVP) showed a 7-mm stone in the middle calices of the right kidney. Extracorporeal shock wave lithotripsy was then performed with a Dornier Compact-S lithotriptor requiring 5500 shocks at a potency of 6 (on a 1-9 scale). There was apparently no difficulty with stone fluoroscopic localization.Thereafter, the patient had 30 days of continuous pain in the flank and right upper quadrant. A plain radiograph of the abdomen disclosed a 4-mm stone in the pelvis of the right kidney. Ultrasound examination was not performed, as the stone was thought to be the cause of the pain. Extracorporeal shock wave lithotripsy was repeated under fluoroscopic guidance. The stone was completely fragmented with 2500 shocks at a potency of 6. In none of the ESWL procedures were antibiotics used, following the standard protocol of our service.Right upper quadrant pain persisted in the same fashion for 2 more consecutive months, now associated with occasional fever and weight loss (5 kg). Physical examination showed tenderness of the right upper quadrant of the abdomen. Hemoglobin was 12.2 g%, white blood cells 11800 mm 3 , urea 36 mg/dL, and creatinine 0.9 mg/dL. The urine culture was negative. Abdominal ultrasound revealed a 9.9 x 6.7 x 7.6-cm heterogenic mass in the inferior portion of the right hepatic lobe. All tumor markers for liver were negative. A computed tomography (CT) of the abdomen demonstrated a round, 6.0-cm diameter collection of fluid and air in the undersurface of the right hepatic lobe (Figure 1). A magnetic nuclear resonance (MRI) of the abdomen disclosed a 7.0-cm diameter homogeneous mass in the right hepatic lobe, suggestive of a hepatic abscess (Figure 2).The fluid collection was percutaneously drained, revealing 60 mL of brownish viscous fluid, suggesting a liquefied hematoma. Culture showed Klebsiella sp as an infecting organism. Fourteen days of third generation cepha- Figure 1 -Computed tomography image of the abdomen showing a gascontaining fluid collection...