Knotting of Guide Wires During Percutaneous Nephrolithotomy: A Complex Intraoperative Challenge

TL;DR

This case report describes a rare complication during kidney stone surgery where a guidewire becomes knotted, and how it was successfully managed.

Contribution

The paper presents a novel case and management strategy for guidewire knotting during PCNL, a rare intraoperative challenge.

Findings

Guidewire knotting occurred during PCNL in a patient with prior interventions.

A secondary puncture was used to safely remove the knotted guidewire.

Successful stone clearance and recovery were achieved with proper management.

Abstract

Percutaneous nephrolithotomy (PCNL) is the gold standard for managing complex renal calculi, offering high stone-free rates with minimal invasiveness. Despite its safety, intraoperative complications can present significant challenges. This case highlights a rare but critical complication - guidewire knotting during PCNL - and outlines the intraoperative strategy employed for its successful resolution.

A 35-year-old male with recurrent left flank pain and prior retrograde intrarenal surgery (RIRS) and PCNL underwent prone PCNL for residual renal calculi and a retained double-J (DJ) stent. During renal access, significant resistance was encountered while advancing a super-stiff guidewire. Fluoroscopy confirmed guidewire knotting within the pelvicalyceal system, posing a risk of ureteral injury or fracture. Gentle traction failed, necessitating a secondary puncture to establish an alternative access route, enabling safe removal of the knotted guidewire. The procedure continued successfully, achieving complete stone clearance, and a new DJ stent was placed.

The patient had an uneventful recovery, with stone-free status confirmed at six weeks. Guidewire knotting is a rare but significant challenge in PCNL, particularly in patients with prior interventions. This case underscores the importance of meticulous fluoroscopic monitoring, early recognition of intraoperative resistance, and a structured problem-solving approach. Awareness of such complications and alternative access strategies can help optimize patient safety and surgical outcomes in complex stone disease.

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