Kidney transplantation (KT) is the optimal treatment for end-stage kidney disease, yet allograft stones can lead to significant complications, including obstruction, infection, and graft dysfunction. Allograft lithiasis occurs in 0.1–6.3% of recipients, typically within 1.6–3.5 years post-transplant. Historically, kidneys from donors with stones were avoided; however, currently, 84% of transplant centers in the United States accept donors with asymptomatic stones, substantially expanding the donor pool. Treatment options parallel those for solitary kidneys and include active monitoring, extracorporeal shock wave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PCNL). Endoscopic Combined Intrarenal Surgery (ECIRS) is an emerging approach especially beneficial for large or complex stones. We describe our early experience employing ECIRS to effectively treat a large donor-gifted renal graft stone.

A 47-year-old woman with end-stage renal disease of unknown etiology who had undergone continuous ambulatory peritoneal dialysis for six years received a kidney transplant from a 42-year-old male deceased donor who died from a ruptured cerebral aneurysm. The donor had no known urologic history; pre-donation ultrasound and urine analysis were unavailable. The transplant was completed successfully, with a cold ischemia time of 22 hours and 6 minutes. Postoperatively, the patient maintained stable renal function without dialysis. On day 10, serum creatinine was stable at 3.04 mg/dL, and urine output was 4,500 mL/day. A non-contrast CT scan identified a large renal pelvis stone measuring 32 × 30 × 16 mm³ (1660 HU) with additional smaller calyceal stones and mild hydronephrosis.

At six weeks post-transplant, the patient underwent ECIRS, successfully achieving complete stone removal. The postoperative recovery was uncomplicated, without adverse events. Follow-up ultrasonography confirmed no residual stones and showed only mild hydronephrosis.

Kidney donation from carefully evaluated donors with asymptomatic stones is both practical and safe. ECIRS is an effective, feasible, and minimally morbid technique for managing large stones in renal transplant recipients. Collaboration with experienced endourologists significantly contributes to favorable outcomes.