INTRODUCTION: Percutaneous nephrolithotomy (PNL) remains the treatment of choice for managing patients with large or complex renal calculi, especially staghorn stones composed of struvite. Recent advances in the PNL technique appear to improve post-operative outcomes and reduce patient morbidity. MATERIALS AND METHODS: A thorough review of the recent urologic literature was performed to identify results and, benefits of percutaneous nephrolithotomy versus either combination PNL and shock wave lithotripsy or SWL alone. A brief description of these three modalities is presented. RESULTS: Published series from several different centers, as well as the 2004 report from the AUA Nephrolithiasis Guidelines Panel have demonstrated superior stone-free rates, improved complication rates and a reduced need for secondary procedure in those patients treated with PNL monotherapy. Combination techniques or SWL treatment may be beneficial in patients with low-volume renal stone disease. CONCLUSIONS: Further advances in the PNL technique will not only increase stone-free outcomes and reduce post-operative complications, but also significantly reduce peri-operative patient morbidity. PNL monotherapy should be considered first line therapy for those patients with large or complex renal calculi.