Background <p>Percutaneous nephrolithotomy is a procedure for managing large and complex renal stones. Supracostal approach is sometimes necessary for treating upper pole stones or staghorn calculi providing direct access to the upper calyces. However, supracostal approach raises concerns about risk of bleeding and thoracic complications.</p> Methods <p>This was a retrospective, single-surgeon series included patients with large renal stones (&gt; 2&#xa0;cm) underwent supracostal PCNL using lateral intercostal approach between June 2019 and March 2024. This study aimed to evaluate the safety and efficacy of supracostal approach using lateral intercostal access.</p> Results <p>142 patients were included in the study. All patients underwent supracostal puncture with lateral access to the upper calyx above the infundibulum. Upper calyx stones were found in 99 cases (69.7%), and upper associated with renal pelvic stones 43 cases (30.3%). A single tract access was used in 120 cases (84.5%), a second tract was needed in 22 (15.5%). Percutaneous nephrostomy (PCN) was left for drainage in 11 (7.7%) cases, double J catheter and PCN 128 (90.1%) and 3 (2.1%) were tubeless.</p> <p>Eight patients had Intraoperative blood loss with hemoglobin below 10&#xa0;g/dL that needed blood transfusion and no further intervention. One case was admitted to the ICU with postoperative sepsis and was successfully recovered. None of our patients had late postoperative bleeding or adjacent organ injury, one minimal pleural effusion managed conservatively. The stone-free rate was 94.4% (134/142).</p> Conclusion <p>The lateral intercostal access technique for supracostal PCNL is associated with a high stone-free rate and a notably low incidence of thoracic complications, offering a safe and effective alternative for managing complex upper pole renal stones.</p>