522 JOURNAL OF ENDOUROLOGY Volume 20, Number 7, July 2006 © Mary Ann Liebert, Inc. Beware! Fungal Urosepsis May Follow Endoscopic Intervention for Prolonged Indwelling Ureteral Stent GAGAN GAUTAM, M.S., DNB, M.Ch., 1 A.K. SINGH, M.S., 1 RAJEEV KUMAR, M.Ch., 1 A.K. HEMAL, M.Ch., 1 and ATUL KOTHARI, M.D. 2 ABSTRACT We present a 38-year-old lady with a prolonged indwelling ureteral stent that had been placed for pain re- lief after development of Steinstrasse following extracorporeal lithotripsy for a 2.5-cm left renal calculus. The patient developed candidal urosepsis within 6 hours after ureteroscopy and percutaneous nephrolithotomy (PCNL) for the removal of residual fragments. She subsequently recovered on systemic antifungal therapy in the form of intravenous amphotericin B and achieved complete stone clearance after repeat ureteroscopy and PCNL. Fungal urosepsis is known to complicate the postoperative course in chronically debilitated patients with poor nutritional status or those with diabetes or other significant comorbities. To our knowledge, this is the first reported case of a patient with no significant comorbities developing fungal urosepsis after endo- scopic intervention for a long-term indwelling ureteral stent. INTRODUCTION F UNGAL UROSEPSIS is a potentially fatal condition that can occur postoperatively in patients with significant co- morbidities, poor nutritional status, or a chronic focus of in- fection such as a colonized indwelling ureteral stent. 1 We pre- sent a forgotten ureteral stent and Steinstrasse leading to fungal urosepsis after ureteroscopy and percutaneous nephrolithomy (PCNL). CASE REPORT A 38-year-old nondiabetic hypertensive lady presented with left flank pain, frequency of micturition, and dysuria of 6 months’ duration, which had increased in severity over the past month. She had had a ureteral stent on the left side for the last year that had been placed at another institution to relieve pain after the development of Steinstrasse following two sessions of extracorporeal shockwave lithotripsy (SWL) for a 2.5-cm left renal calculus. The stent had subsequently been forgotten. The patient did not have any history of steroid intake or any im- munosuppressive illness. Examination revealed no abnormality. Her hemogram and renal and liver function were normal. Radiography revealed a double-J stent in the left ureter along with Steinstrasse and re- sidual calculi in the renal pelvis and the inferior calix. An in- travenous urogram (IVU) showed a moderately hydronephrotic left kidney with delayed function and a normal right kidney (Fig. 1). The patient was started on oral ciprofloxacin 500 mg daily for 1 week prior to the planned endoscopic procedure. Preoperative urine microscopy revealed 5 to 10 white blood cells/high-power field with no evidence of yeast cells. Urine culture was sterile with no bacterial or candidal growth. The patient underwent cystoscopy and removal of the stent followed by left-sided rigid ureteroscopy. The stent was found to be encrusted with debris but could be removed with rela- tive ease. Stone fragments were further pulverized using a Lithoclast and removed. Residual fragments in the ureter were washed up into the kidney using hydraulic pressure. An open- ended ureteral balloon catheter was placed at the ureteropelvic junction under fluoroscopic guidance with the patient in a Trendelenburg position, and the balloon was inflated to pre- vent downward migration of fragments. The patient was then turned prone, and PCNL was done for the renal fragments us- ing a single inferior-caliceal puncture. The overall procedure 1 Department of Urology, All India Institute of Medical Sciences, New Delhi, India. 2 Department of Microbiology, Max Devki Devi Hospital, New Delhi, India.