Perils of guide wire fracture - Unrecognized retained foreign body.

A case is presented of retained guide wire fragment after percutaneous stone removal with probable mechanism of breakage. Nephrostomy access was obtained using Seldinger technique and the wire passed through a stenotic ureter with difficulty. After removal of the stone, the wire fragmented on removal and the upper and lower fragments were removed from above and below, respectively. Years later, recurrent stone in the kidney contained an unsuspected wire fragment. Guide wire fracture may result in multiple fragments within the urinary tract. An understanding of mechanisms of wire failure may prevent unsuspected retained foreign bodies.