title: Fungal urosepsis after ureteroscopy in cirrhotic patients: a word of caution.
abstract: OBJECTIVE
  Fungal sepsis after ureteroscopy (URS) is rarely reported. We report on 2 cases of acute fungemia that developed after routine ureteroscopic stone manipulation in patients with advanced liver cirrhosis. This represents a unique and high-risk population, and, to our knowledge, these are the first such cases reported.
  
  
  METHODS
  We performed a retrospective review of the medical records of 2 patients with Child-Pugh class B and C liver cirrhosis who had undergone ureteroscopy (URS) and holmium laser lithotripsy for obstructing ureteral calculi.
  
  
  RESULTS
  The treated stones measured 10 mm and 12 mm and were at the right ureteropelvic junction and left ureterovesical junction, respectively. Both patients had had indwelling ureteral stents in place for 1 and 2 months before URS plus holmium laser lithotripsy, with negative preoperative urine cultures. Each procedure was uncomplicated, and a ureteral stent was left in situ in each case. Within 12 hours of URS, each patient became tachycardic, hypotensive, and febrile. Blood, urine (proximal to the stone), and stone cultures were positive for Candida albicans in both patients. They were both successfully treated with intravenous fluconazole and subsequently discharged from the hospital on postoperative day 12 and 13, respectively.
  
  
  CONCLUSIONS
  Patients with advanced liver disease appear to be at greater risk of fungal sepsis after otherwise uncomplicated URS and stone manipulation. Consideration should be given to prophylactic antifungal therapy, in addition to the standard antibacterial prophylaxis for such procedures.
authors.affiliation: Department of Urology, University of California, Irvine, School of Medicine, Orange, California 92868, USA. sbeck@uci.edu
authors.forename: Shawn M
authors.initials: SM
authors.lastname: Beck
authors.forename: David S
authors.initials: DS
authors.lastname: Finley
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Deane
mesh_terms: D006801:Humans; D007669:Kidney Calculi / Q000150:complications*; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D018805:Sepsis / Q000382:microbiology* / Q000652:urine*; D018666:Ureteroscopy / Q000009:adverse effects*