Abstract : Percutaneous nephrolithotomy (PCNL) is frequently performed by Urologist as a main way of management of renal stones of large size. Fluoroscopy is used commonly to guide Percutaneous nephrolithotomy (PCNL) with the hazards of radiation to the patients and the operating team, that is why Ultrasound represents a good lower cost alternative to guide this procedure as it gives a better needle access, ensures urinary tract dilatation and localization of small residual radiolucent stones.Also; it has lesser risk of adjacent organs’ injuries. Patients and methods: In this prospective interventional study, one hundred ninety-three patients, aged 12 years and morewith staghorn renal stones of 70 millimeters diameter and less involved for the period of January 2012 till March 2019. All patients underwent necessary basic blood,urine and imaging studies for preoperative assessment. Patients divided into two groups based on the image guiding the operation, those who underwent Ultrasound guided Percutaneous nephrolithotomy (PCNL) were 115, and the rest 78 underwent Fluoroscopy guided Percutaneous nephrolithotomy (PCNL). Then, under general anesthesia; stone extraction performed with intraoperative assessment of operative time, total time of access, exposure time to radiation. And post-operative follow up of patients for complications and outcomes including stone free rate, any residual stone, need for ESWL or for second PCNL, failure of needle access, hospital stay, bleeding or hematuria, need for blood transfusion or embolization, fluid extravasation, fever or sepsis, Colonic or inferior vena cava injury, Pneumothorax or hemothorax. Results: The two groups were homogenous regarding gender and age, serum creatinine and hemoglobin concentration were not different between them pre-operatively. There was a higher stone free rate by using Ultrasonic guided percutaneous nephrolithotomy, and there was no statistical difference between the two procedures regarding the risk of injury to internal organs and bleeding, and both procedures did not cause colonic, hepatic or splenic injuries. Operative time, post-operative hospital stay and post-operative extravasation, fever, and sepsis were not significantly different between the two groups. Conclusion: Apart from stone free rate and radiation exposure, both ultrasonic- guided, and Fluoroscopy guided Percutaneous nephrolithotomy have the same value as surgical procedures for treatment of renal stones, and there was no significant difference between them.