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Introduction: The management of urinary tract stones, particularly de novo kidney allograft stones, presents unique challenges for kidney transplant recipients because of their prevalence and specific clinical considerations. Here, we describe a case in which percutaneous nephrolithotomy was successfully used to fragment a large kidney allograft stone ≥20 mm in size., Case Presentation: A 57-year-old woman who underwent ureteroureterostomy post simultaneous pancreas-kidney transplantation presented with gross hematuria after 15 years. Computed tomography revealed a 23-mm stone in the transplanted kidney. Initial attempts at endoscopic combined intrarenal surgery were changed to percutaneous nephrolithotomy because of poor ureter mobility and tortuosity. Stone fragmentation was achieved using pneumatic and ultrasonic lithotripsy. A second procedure using Swiss LithoClast ® Trilogy enabled complete stone clearance and ureteral stent placement., Conclusion: By understanding the peculiarities of the percutaneous approach, we demonstrated the safe and effective use of a pneumatic and ultrasonic lithotripter for kidney allograft stone fragmentation., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of Japanese Urological Association.)