<p>Pancake kidney is a rare congenital renal fusion anomaly characterized by complete fusion of both kidneys in the pelvis with separate collecting systems and ureters. Abnormal position, malrotation, and aberrant vasculature predispose these kidneys to urinary stasis and stone formation, making surgical management challenging. We report a 39-year-old male presenting with intermittent lower abdominal pain and graveluria. Imaging revealed a fused pelvic renal mass at the L4–S1 level with bilateral renal pelvic calculi and hydronephrosis, consistent with a pancake kidney. Owing to high stone burden, anteriorly oriented renal pelvis, and complex vascular anatomy, minimally invasive approaches were considered unsuitable. The patient underwent open bilateral pyelolithotomy through a lower midline incision. Complete stone clearance was achieved, and the postoperative course was uneventful. This case underscores the continued relevance of open pyelolithotomy in selected patients with complex renal fusion anomalies and significant stone burden. While minimally invasive techniques are preferred in most cases, open surgery remains a safe and effective option when anatomical factors limit endourological approaches.</p>