Introduction: Optimum calculi clearance particularly in staghorn and renal calculus relies heavily on proper preoperative renal access. Percutaneous nephrolithotomy (PCNL) has been the surgery of choice for large renal calculi. But it is pertinent to realise that not all stones can be cleared by the most favoured infracostal approach.To gain further insight we compared supracostal to infracostal approach of PCNL in terms of stone clearance, surgical ease and complications. Aims and Objectives: A prospective study was conducted to compare supracostal versus infracostal approach in PCNL for removal of complex renal calculi. Materials and Methods: A total of 90 patients with comple renal stones were recruited for PCNL in our Tertiary care referred between January 2018 to November 2019. Fourtyeight of them underwent supracostal, while Fourty two underwent infracostal puncture. The two
approaches were compared on various parameters like a total duration of surgery, intraoperative blood loss, infundibular/pelvic tear, rate of complete stone clearance and postoperative complications (pulmonary, bleeding, fever and sepsis, etc.). Observation and Results: In our study, the success rate was 72% for those in the infracostal 87% for those in the supracostal approach.21.4% required secondry puncture while 26% required so in infracostal approach. There was no statistically significant difference noted in terms of mean operative time and duration of inpatient stay. In terms of complication blood transfusion was more in infracostal approach.Thoracic complications (hydrothorax) which is most feared in supracostal approach happened in just 1 patient. Conclusion: Supracostal approach when judiciously used in properly selected patients can offer better calculi clearance with less rate of secondary punctures, peroperative complications and lesser need for ESWL.

Keywords: Percutaneous; Nephrolithotomy; Staghorn; Supracostal Puncture.