Objective To evaluate the predictive value of renal stone CT attenuation and stone surface area (SSA) for residual fragments after percutaneous nephrolithotomy (PCNL) with holmium laser lithotripsy. Methods A total of 120 patients with renal stones who undergoing PCNL between August 2020 and November 2025 at Puyang Oilfield General Hospital were retrospectively enrolled. According to postoperative imaging, patients were assigned to residual fragment group (n＝23) and stone-free group (n＝97). Baseline clinical data, CT attenuation values, and SSA were collected. Univariate and multivariate Logistic regression was performed to identify independent risk factors. Receiver operating characteristic (ROC) curves were constructed to evaluate the predictive performance of CT attenuation, SSA and their combination. Results Significant differences were found between two groups in hydronephrosis grade, CT attenuation, SSA and operation time (all P＜0.05). Logistic regression demonstrated that higher CT attenuation and larger SSA were both independent risk factors for residual fragments after PCNL (both P＜0.05). ROC analysis revealed that the area under the curve (AUC) of the combined model was significantly higher than that of single indicators (P＜0.05). Conclusion Preoperative renal stone CT attenuation and SSA are independent risk factors for residual fragments after PCNL. Combined assessment of these two parameters yields high predictive performance, supporting individualized surgical planning.