Percutaneous nephrolithotomy (PCNL) is the most morbid of the minimally invasive surgeical procedures for stone removal. Over the last 2 decades, refinements in technique and new technology have improved the efficacy and the efficiency of the procedure. Although PCNL has long been the procedure of choice for large and complex stones, it is increasingly being used for moderate stone burdens because of its high stone-free rates and because of the limitations of shock wave lithotripsy and ureteroscopy. The article reviews advances in the technique and technology applied to percutaneous access, tract dilation, stone visualization, stone fragmentation, stone clearance, and postoperative management.