case_images: PMC11693098_01
case_images: Preoperative CT images of a kidney allograft stone. The present case pertained to a simultaneous pancreas-kidney transplant recipient, with the transplanted kidney placed in the left iliac fossa. The transplanted renal pelvis showed a stone measuring 23 mm in its longest diameter, with an average CT value of 856 Hounsfield Units (maximum, 1092; minimum, 504).
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case_images: Fifteen years after transplantation, the patient had gross hematuria, and CT revealed a 23-mm stone in the transplanted kidney (Fig. 1).
case_images: Retrograde pyelography findings and creation of a percutaneous tract. (a) Intraoperative retrograde pyelography findings. The asterisk (*) indicates the site where considerable bending of the ureter was observed (presumed to be the anastomosis site between the native and transplanted ureters). While contrast flow was observed, ureteral mobility was poor; thus, the passage of a ureteral catheter or ureteral access sheath was not feasible. (b, c) Percutaneous renal transplant puncture was performed, and a 24-French tract was placed. The puncture was directed toward the upper renal calyx, and an echo-free space was identified.
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case_images: We initially planned endoscopic combined intrarenal surgery but switched to PCNL using a 6/7.5-French rigid ureteroscope (Richard Wolf, Germany) because of poor ureter mobility near the anastomosis and significant tortuosity, preventing retrograde access (Fig. 2a). A 24-French percutaneous tract was created toward the upper pole of the transplanted kidney under ultrasonography and fluoroscopic guidance (Fig. 2b,c).
case_images: Intraoperative findings and the device used for lithotripsy. (a) Stone fragmentation and aspiration were performed using ultrasonography: intraoperative findings during the initial surgery. (b) Swiss LithoClast  Trilogy lithotripter was used for the second procedure in this case; the lithotripter enables pneumatic and ultrasonic lithotripsy with a single handpiece without the need to exchange probes.
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case_images: Stone fragmentation was achieved using a combination of pneumatic and ultrasonic lithotripsy (Swiss LithoClast  Master-J, Switzerland) (Fig. 3a). Swiss LithoClast  Trilogy, which integrates pneumatic and ultrasonic lithotripsy without the need for probe exchange (Fig. 3b). Smooth stone fragmentation and suctioning resulted in complete stone clearance.
case_images: Postoperative CT images. On postoperative Day 1, CT shows that both the nephrostomy catheter and ureteral stent were in place. No residual fragments were observed. The nephrostomy catheter was subsequently removed.
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case_images: This facilitated the removal of the nephrostomy tube on the first postoperative day after confirming the absence of substantial residual fragments on CT (Fig. 4).