# 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.

## Key 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.