Anatrophic nephrolithotomy is a procedure in which a parenchymal incision is made in an intersegmental plane, allowing removal of large renal calculi.A flank incision is made and the kidney carefully mobilized. The main renal artery is isolated and the posterior segmental artery identified. The anatrophic plane is defined by occluding the posterior segmental artery and administering methylene blue intravenously. Renal hypothermic ischemia is established, and a nephrotomy is made through the previously identified plane. The calculi are extracted, which may require incising stenotic infundibula to facilitate removal. Intraoperative radiography is performed to confirm complete stone removal. The collecting system is reconstructed with absorbable suture, and special techniques are used to correct the infundibular stenosis. The renal capsule is closed with absorbable suture after which the renal circulation is re-established.This procedure is currently used to treat patients with large-volume staghorn calculi and complex collecting system anatomy.