To prospectively evaluate the safety and efficacy of the supracostal approach for percu-taneous nephrolithotomy (PCNL), as it is usually avoided because of concerns about potential chest complications. Between August 1998 and August 2001, 465 patients underwent PCNL. Supracostal access was obtained in 62 patients (63 renal units), comprising 13% of the procedures. The indications for a supracostal approach were staghorn, upper ureteric, superior calyceal stones and high-lying kidneys. The data were analysed for stone clearance, need for additional punctures and the complications associated with supracostal puncture. The supracostal was the only access in 63% of the PCNL procedures. Additional punctures were required mainly for staghorn stones (15 of 23). Overall, 90% of the patients were rendered stone-free or had clinically insignificant residuals with PCNL alone. In patients with staghorn stones, they were completely cleared in 84% of renal units. Significant chest complications developed in three (5%) patients, which required insertion of a chest tube. One (2%) patient developed haemothorax secondary to injury of the intercostal artery. All the patients recovered uneventfully. These results indicate that supracostal access provides high clearance rates with acceptable complications; it should not be avoided for fear of chest complications. A chest X-ray after surgery should be routine, to detect any complication.