Abstract This study aimed at investigating the efcacy and safety of retrograde intrarenal surgery (RIRS) in treatment of renal pelvic stone larger than 2 cm against the percutaneous nephrolithotomy (PCNL). Between March 2018 and December 2020, 121 patients were randomized to undergo PCNL (60 patients), or RIRS (61 patients). Both groups were compared in terms of operative time, intraoperative complications. Postoperative complications were assessed based on Clavien–Dindo grading system. Stone-free rates were evaluated by CT scan 6 weeks after surgery. No signifcant diference were observed between both groups in perioperative criteria. The main operative time was slightly longer in PCNL group (105 vs 95 min, p= 0.49). Stone clearance was higher in PCNL, yet the diference was not signifcant. (53 patients in PCNL group had either complete clearance or residual fragments<4 mm, compared to 49 in RIRS group (p=0.22). Blood transfusion rate was 8.3% in PCNL compared to 1.6% in RIRS group, with a trend towards signifcance (p = 0.08). Post-operative fever was higher in RIRS, yet it fell just short of statistical signifcance (13.1% vs 5.0%, p=0.12). Compared to PCNL, RIRS displayed acceptable efcacy with less risk of bleeding requiring transfusion. It can be applied to patients with large renal pelvic stone as an alternative to PCNL.