# Ahmed AF. et al., 2026: Prospective randomized trial comparing mini-percutaneous nephrolithotomy, retrograde intrarenal surgery, and shock wave lithotripsy for treatment of medium-sized high-density renal stones. Hans-Göran Tiselius Monday, 21 September 2026 314 Hits [ 0 Comments ](https://www.storzmedical.com/en/disciplines/literature-database-blog/database-lithotripsy/ahmed-af-et-al-2026/?layout=listings#comments) Ahmed AF, Raafat M, ElDamanhory H, Abdelazim H, Soliman A, ElShazly A, Hindawy M, Anwar M, Algammal M, Soliman A, Daoud A. Int Urol Nephrol. 2026 Jun;58(6):2025-2035. [doi: 10.1007/s11255-025-04928-x](https://pubmed.ncbi.nlm.nih.gov/41385038/) Epub 2025 Dec 12 ## Abstract Purpose: To compare the efficacy and safety of different treatment modalities, mini-percutaneous nephrolithotomy (mini-PNL), retrograde intrarenal surgery (RIRS), and extracorporeal shock wave lithotripsy (SWL), for the management of medium-sized, high-density, non-lower-pole renal stones. Methods: Between November 2021 and March 2025, adults with single renal stones of 10-20 mm and ≥ 1000 HU were prospectively randomized to mini-PNL, RIRS, or SWL. Procedures were performed by experienced endourologists using standardized protocols. The primary outcome was stone-free rate (SFR) at 3 months, defined as no residual fragments > 4 mm on NCCT. Secondary outcomes included operative and fluoroscopy times, hospital stay, retreatment, perioperative complications, and treatment costs. Analyses followed the intention-to-treat principle. Results: Of 330 enrolled patients, 304 completed the study (mini-PNL, n = 105; RIRS, n = 103; SWL, n = 96). Final SFRs were 96.2% for mini-PNL, 91.3% for RIRS, and 51.0% for SWL. Both mini-PNL and RIRS achieved significantly higher SFRs than SWL (p < 0.001), with mini-PNL demonstrating superior single-session clearance. Operative time was shortest with SWL, fluoroscopy exposure was lowest with RIRS, and hospital stay was shortest with RIRS, while SWL was performed on an outpatient basis. Overall complications were 11.4% (mini-PNL), 22.3% (RIRS), and 16.7% (SWL), with no significant differences (p = 0.109) or in high-grade events (p = 0.879). Median treatment costs per stone-free patient were 24,121 EGP for mini-PNL, 57,100 EGP for RIRS, and 23,843 EGP for SWL. Conclusions: In conclusion, mini-PNL and RIRS are more effective than SWL, with mini-PNL offering the best balance of efficacy and safety, and RIRS a less invasive but more costly option. ## Comment Hans-Göran Tiselius The report compares treatment results of removal of lower pole stones with a density ≥ 1000 HU. The stones measured 10-15 mm. The outcome was expressed in in terms of stone-free rates, that was either completely without residuals or with fragments ≤4 mm. The applied endoscopic and non-invasive procedures and the stone-free rates were as follow: Method SFR Mini-PNL 96.2% RIRA 91.3% SWL 51% The outcome is similar to that repeatedly shown in the literature during recent years. But also, in view of the hardness of the stones, is the SWL result worse than expected. That stone clearance would be inferior for SWL-treated patients compared with that after mini-PNL and RIRS is expected, but it is surprising that the stone-free rates obtained with the invasive procedures was about double that following SWL. That is a pattern of results that is not easy to accept. Whereas the results of endoscopic procedures seem to be in steady rise, that of SWL apparently moves in opposite direction. It is surprising that the authors did not comment on this drawback and how to deal with it. It is well recognized that urologists in general have low interest in SWL and accordingly will get inferior results. It is also problematic that whereas mini-PNL and RIRS have undergone an astonishing technical improvement, a corresponding development cannot be discerned for SWL. Given the favourable properties of SWL, some improvements in its technology would have been expected. My message to the manufacturers of SWL devices is that there definitely are possibilities for technical improvements. Unfortunately, there still is a misunderstanding that increments of the energy levels lead to need of anaesthesia. This is not the case, and it would be interesting to see SWL-results corresponding to those that were encountered with the unmodified Dornier HM3-lithotriper, only with analgesics. *Hans-Göran Tiselius* 0 #### Comments No comments made yet. Be the first to submit a comment Monday, 09 November 2026 I have read and agreed to the [Privacy Policy](https://www.storzmedical.com/javascript:void(0);)