Following initial reports of prone percutaneous access to the upper urinary tract for the removal of renal calculi in 1976, percutaneous nephrolithotomy in the prone position quickly became the standard technique for the treatment of complex renal and proximal ureteral calculi. Rapid advancements in endourological technology have made this approach more feasible and widely performed. Strategies have been aimed at maximizing the use of rigid instruments, minimizing morbidity, and allowing for adjunctive procedures when necessary. This chapter will address the preoperative planning, intraoperative instrumentation, and techniques of prone PCNL, and postoperative management of these patients in a stepwise fashion.