Management of Renal Stones >2 cm in the Modern Endourology Era: Does PCNL Remain the Gold Standard?

Abstract

Background: Percutaneous nephrolithotomy (PCNL) remains the reference treatment for renal stones larger than 2 cm because of its high single-session stone-free rate. However, advances in flexible ureteroscopy (fURS), laser lithotripsy, suction-assisted access systems, and endoscopic technology have expanded the role of retrograde intrarenal surgery (RIRS) in patients who historically would have been treated primarily with PCNL. Objective: To critically review the contemporary roles of PCNL and RIRS in the management of renal stones >2 cm and evaluate whether advances in endoscopic and laser technologies have altered the traditional treatment paradigm. Methods: A focused narrative review of the contemporary literature was performed using PubMed, Scopus, and Web of Science. Priority was given to randomized trials, prospective comparative studies, multicenter registries, systematic reviews, meta-analyses, and international guideline recommendations evaluating efficacy, safety, retreatment, operative burden, and technological developments relevant to the management of large renal stones. Results: PCNL continues to provide the most reliable single-session stone clearance for large and complex renal calculi, particularly in patients with high stone burden and staghorn disease. RIRS offers lower procedural morbidity and faster recovery but may require staged procedures as stone burden increases. Recent developments, including thulium fiber laser, pulse-modulated Holmium:YAG systems, suction-assisted ureteral access sheaths, improved digital ureteroscopy, and intrarenal pressure-control strategies, have increased the efficiency and potential applicability of RIRS for larger stones. Nevertheless, current evidence does not support replacing PCNL as the reference treatment for complex or high-volume stone disease. Conclusion: PCNL remains the reference standard for renal stones >2 cm when maximal single-session clearance is the principal objective. Modern RIRS increasingly represents a clinically relevant alternative in appropriately selected patients. Rather than defining a single superior procedure, contemporary management should integrate stone burden and complexity, patient comorbidity, treatment goals, available technology, and local expertise.