摘要目的:探讨上尿路结石治疗中合并真菌感染患者的临床特点、手术时机及抗菌药物的合理应用。方法:回顾性分析2017年4月至2019年4月北京同仁医院收治的4例在上尿路结石治疗过程中出现真菌感染的患者。例1男性，55岁，既往有糖尿病、高血压病、多次体外碎石史。因发热性尿路感染收入肾内科，抗菌治疗期间发现右输尿管结石，转泌尿外科行输尿管镜碎石术后出现发热及真菌性败血症。例2女性，48岁，既往有糖尿病、高血压病。外院右肾经皮肾镜碎石术后出现尿频、尿急，尿常规检查示白细胞满视野，尿细菌培养为白色假丝酵母菌。口服氟康唑200 mg，每日1次，治疗2周症状消失，尿细菌培养转阴。停用氟康唑后2～4周症状复发并尿细菌培养结果转阳，病情反复迁延1年。我院CT检查示双肾多发小结石，右肾结石为残石或复发无法明确。例3男性，74岁，既往有糖尿病、高血压病、高脂血症、乙状结肠癌根治术后。左侧输尿管软镜钬激光碎石术后出现尿频、尿急、尿痛，尿常规检查示白细胞满视野，尿细菌培养为白色假丝酵母菌，依据药敏口服氟康唑200 mg，每日1次，治疗2周后症状略有缓解但尿细菌培养不转阴，停用氟康唑后症状加重，病情迁延1.5年，CT检查示左肾下盏结石。例4男性，47岁，既往体健。左肾结石术后反复尿频、尿急、尿痛0.5年，尿常规检查示白细胞满视野，尿细菌培养为热带假丝酵母菌，合并左肾铸型结石。结果:例1患者输尿管镜钬激光碎石术后出现真菌血流感染，予静脉滴注氟康唑200 mg，每日1次，抗真菌治疗后体温正常，出院后1周出现真菌性眼内炎于眼科继续治疗。例2患者一期行双侧输尿管支架管置入引流，同时口服氟康唑200 mg，每日1次，治疗2周后行双侧输尿管软镜碎石术，术后尿路真菌感染治愈。例3患者行左侧输尿管支架管置入引流，同时采用两性霉素B、氟康唑抗真菌治疗，体温正常后行输尿管软镜钬激光碎石术，但术后口服氟康唑200 mg，每日1次，抗真菌治疗仅至术后1周，导致左肾盂内真菌球形成并二次行输尿管软镜手术清除肾盂内真菌球，术后予口服氟康唑200 mg，每日1次，配合氟康唑300 mg肾盂内持续滴注1周，最终治愈。例4患者行经皮肾造瘘引流配合口服氟康唑200 mg，每日1次，2周后行经皮肾镜超声碎石术，术后持续口服氟康唑200 mg，每日1次，至支架管拔除、尿细菌培养转阴，患者治愈。结论:糖尿病是上尿路结石合并真菌感染的高危因素。对于此类患者如不彻底清除结石，真菌感染难以控制，术后易复发。应在抗真菌治疗的基础上清除结石，术后应持续抗真菌治疗直至尿路支架管拔除后至少2周。真菌血流感染诊断后的1周内应行眼科检查筛查眼内炎，明确有无组织播散，以决定疗程。

abstractsObjective:To discuss the clinical management, such as characteristics, surgical timing and rational application of antifungal drugs in patients of upper urinary calculi with fungal infections.Methods:A retrospective analysis was performed on 4 patients with fungal infections during the treatment of upper urinary calculi from April 2017 to April 2019. Case 1, male, 55 years old, was admitted to the Department of Nephrology due to febrile urinary tract infection. Right ureteral stone was found during antibacterial treatment. Fever and fungal sepsis occurred after transurethral ureteroscopic lithotripsy. Case 2 Female, 48 years old, frequency and urgency occurred after percutaneous nephrolithotomy of right kidney in another hospital. Urine routine WBCs were full of vision, urine culture was Candida albicans, symptoms disappeared after 2 weeks of oral fluconazole 200 mg QD treatment, urine culture turned negative, discontinued fluconazole symptoms recurred in about 2-4 weeks and the urine culture turned positive, the condition was repeatedly for 1 year. The CT showed multiple small stones in both kidneys. Case 3 Male, 74 years old, frequency, urgency, and dysuria occurred after flexible ureteroscopic holmium laser lithotripsy of left kidney. Urine routine WBCs were full of vision, urine culture was Candida albicans. Symptoms slightly after 2 weeks of oral fluconazole 200 mg QD treatment according to drug sensitivity, but urine culture did not turn negative, discontinued fluconazole symptoms increased. The condition was lasted for one and a half years. His CT showed left kidney lower calyx stones. Case 4 male, 47 years old, frequency, urgency, and dysuria occurred after the surgery of left kidney stone for half a year. Urine routine WBCs were full of vision, urine culture was Candida tropicalis, combined with left kidney cast stones.Results:Case 1, male, 55 years old, was admitted to the Department of Nephrology due to febrile urinary tract infection. Right ureteral stone was found during antibacterial treatment. Fever and fungal sepsis occurred after transurethral ureteroscopic lithotripsy. Case 2 patient was performed bilateral ureteral stent placement for drainage, and two weeks after the oral fluconazole 200 mg QD, she was performed bilateral flexible ureteroscopic lithotripsy, then the urinary fungal infection was cured. Case 3 patient was performed left side ureteral stent placement and amphotericin B and fluconazole antifungal therapy. After his body temperature was normal, he was performed flexible ureteroscopic holmium laser lithotripsy, after the surgery the oral fluconazole 200 mg QD time was just 1 week, resulting in the formation of fungal balls in the left renal pelvis and secondary surgery. Oral fluconazole 200 mg QD combined with fluconazole continuous intraperitoneal perfusion ultimately 1 week cured him after and secondary surgery. Case 4 patient was performed percutaneous nephrostomy drainage and oral fluconazole 200 mg QD for 2 weeks. Then he was performed percutaneous nephrolithotomy lithotripsy, oral fluconazole 200 mg QD was continued until the stent was removed and urine culture turned negative, patient was cured. Case 4 patient had fungal bloodstream infection after ureteroscopic holmium laser lithotripsy. The temperature was normal after intravenous drip of fluconazole 200 mg QD antifungal therapy, and fungal endophthalmitis occurred in ophthalmology 1 week after discharge.Conclusions:Diabetes could be a high risk factor for upper urinary calculi complicated with fungal infection. It is difficult to control the fungal infection without stone removed and it is easy to relapse after surgery. Stones should be removed on the basis of antifungal therapy, and antifungal therapy should be continued after surgery at least 2 weeks after urinary stent removal. If fungal bloodstream infections is diagnosed, eye examination should be done to screen for endophthalmitis to determine if there is tissue dissemination and determine the course of treatment.