Background: Percutaneous nephrolithotomy (PCNL) is one of the most common and effective methods used for removal of large renal stones. PCNL traditionally utilizes fluoroscopy for visualizing the renal stone, creating access, dilating the working tract, and ensuring stone clearance. Percutaneous Nephrolithotomy (PCNL) access to the kidney is performed, mostly under X-Ray fluoroscopy. Providing only two- dimensional image, sometimes includes multiple puncture trials and exposes the patient, personnel and surgeons to ionizing radiation. The same access can be achieved under ultrasound (US) guidance, the aim of the study is to compare Efficacy, accuracy, complications & outcome of ultrasound guided percutaneous nephrolithotomy (US-PCNL) with X-ray guided percutaneous nephrolithotomy (XG-PCNL). Patients and Methods: This study was carried out on forty patients performing radiology (ultrasound / fluoroscopy) guided percutaneous nephrolithotomy admitted in urology department or attending emergency. They were divided as following: Patient group (C-PCNL): twenty patients performing fluoroscopy guided mini- percutaneous nephrolithotomy. Patient group (US-PCNL): twenty patients performing US guided mini-percutaneous nephrolithotomy. All patients with complex calyceal, pelvic, and upper ureteral stones with stone burden of ≥ 20 mm were included (grade II -IV Guys stone score) were included in the study. Results: current study showed that, there was statistically significant difference between C-PCNL and US-PCNL regarding stone free rate. (45.0%) in C-PCNL and (60.0%) in US-PCNL which suggest better stone free rate in US-PCNL. Conclusion: The use of US-PCNL to guide access puncture during PCNL eliminates the risk of inadvertent organ injuries. US-PCNL had better stone free Rate than CPCNL.