The role of surgery in managing large kidney stones

Background: Large renal stones measuring 2 cm or more present management difficulties because of their complex nature and possible complications and inconsistent reactions to surgical methods. The treatment of large kidney stones has evolved through minimally invasive procedures including percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) which now replace open surgery yet the optimal method depends on stone burden and location and anatomical factors. Objectives: The main goal of this research was to compare the outcomes of PCNL, RIRS, and open/laparoscopic surgery for treating big kidney stones in terms of their success rates, complications, and postoperative recovery. Methods: The prospective observational cohort study took place at Tikrit Teaching Hospital in Iraq from January 2024 through January 2025. The research included 250 patients who had kidney stones measuring 2 cm or larger and were distributed across three treatment groups based on surgical approach: Group A received PCNL (n=100), Group B underwent RIRS (n=100) and Group C underwent Open/Laparoscopic surgery (n=50). The research team obtained clinical and radiological data and intraoperative information from patients who received follow-up care for three months after their procedure. The study evaluated stone-free rates together with Clavien-Dindo classification complications and operative time and blood loss and hospital stay duration and requirement for additional procedures. Results: Open/laparoscopic surgery had the highest stone-free rate (93%) but also the highest complication rate (25%) and the longest hospital stay (5.2 ± 1.3 days). RIRS showed the lowest blood loss and complication rate (12%) but had the lowest stone-free rate (81%) and highest need for ancillary procedures (14%). PCNL offered a balanced profile with high efficacy (stone-free rate of 89%) and moderate complication rates. Conclusion: Each surgical modality offers distinct advantages. PCNL remains the most balanced option for large stones, RIRS is safest but less effective for complex stones, and open/laparoscopic surgery should be reserved for select complex cases.