The aim of this study was to evaluate the safety and efficacy of the supracostal access for percutaneous nephrolithotomy (PCNL). Between July 2007 and June 2010, 122 patients underwent PCNL, of whom 28 (23%) had supracostal access. All procedures were performed in a single sitting under general anesthesia. The data were analysed for indications, stone clearance rates and the complications associated with supracostal puncture. The indications for a supracostal access were staghorn stones (50%), pelvis stones (28.5%), calyceal stones in high-lying kidney (18%) and upper ureter/ureteric stones (3.5%). All tracts were made in the 11th intercostal space. Single tract access was used in 22 cases (78%), but 6 (22%) required a second tract. Additional punctures were required mainly for staghorn stones (4 out of 14). Overall, 82% of the patients were rendered stone free or had clinically insignificant residual stones with PCNL monotherapy, and this increased to 96% with secondary procedures. In patients with staghorn stones, they were completely cleared in 78%. Overall complication rate was 28% and included hydrothorax in 3 (10%) patients, which required insertion of a chest tube. One (3.5%) patient developed haemothorax secondary to injury of the intercostal artery, pelvic perforation in 1 (3.5%), perinephric collection in 1 (3.5%), infection/sepsis in 2 (7%). Except those patients who had complication, all other patient recovered uneventfully. Postoperative hospital stay ranged from 2 to 9 days. In conclusion, supracostal access gives high clearance rate with acceptable complications and should not be avoided for fear of chest complications.