Background: Percutaneous nephrolithotomy (PCNL) is a procedure typically performed under general anesthesia (GA); however, many patients might be considered unfit for GA and locoregional anesthesia is their only chance to have the procedure done. Case Presentation: A 60-year-old Middle-Eastern female with end-stage lung disease underwent evaluation for lung transplant; she was found to have severe restrictive pattern on steroid and continuous oxygen therapy, pulmonary hypertension with dilated right ventricle, chronic anemia, and asthma. She had kidney stones for 10 years, having spontaneously passed several in the past. During work-up for a lung transplant, she was found to have bilateral staghorn calculi and was referred to urology for stone management before lung transplant. After insertion of a Double-J stent for management of worsening right hydronephrosis, antibiotic therapy for extended spectrum beta-lactamases Klebsiella pneumoniae, and optimization after two procedure cancellations because of new onset of cardiovascular issues, she had a simultaneous bilateral PCNL under thoracic epidural anesthesia in two stages within 48 hours without significant complications. She was rendered stone-free and a candidate to be added to the lung transplant list. Conclusion: Bilateral prone PCNL under epidural is a safe and effective option in high anesthetic risk patients.