To evaluate the success and morbidity of percutaneous nephrolithotomy (PNL) performed in patients aged 65 years and older.A retrospective review of 42 PNLs performed on 33 patients aged 65 years and older was compared with a cohort of 160 PNLs performed on younger patients over the same time period.The presence of complete staghorn calculi (17 of 36 renal units [47%] versus 88 of 160 renal units [55%], p = 0.46) and average stone size (3.8 cm versus 4.3 cm, p = 0.2) were similar for the 2 groups. Eighty-two percent of patients (27 of 33) were stone-free or left with fragments < 5 mm at 3 months after surgery. Elderly patients had a higher transfusion rate after PNL despite similar preoperative hemoglobin levels (11 of 42 PNLs [26%] versus 22 of 160 PNLs [14%], p < 0.01). Serious complications were infrequent and there were no deaths.Percutaneous nephrolithotomy is a safe and effective therapy for elderly patients with complex stone disease; however, awareness of an apparent increased requirement for blood transfusion is warranted.