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

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.