Percutaneous nephrolithotomy (PNL) is the treatment of choice for patients with large or complex renal calculi. Although injuries to intra-abdominal organs are rare during PNL, splenic injuries have been reported. The management of a splenic injury after PNL is not well defined; therefore, we performed a study to define a management strategy for such an event.A retrospective, multi-institutional study was performed to identify all cases of splenic injury that occurred during PNL. All procedures were performed as a single-stage operation, with percutaneous access obtained in the operating room by the urologist. A review of patient records and imaging was conducted to identify treatment strategies and outcomes.Three patients were identified as having undergone a transsplenic PNL. All puncture sites were upper pole, supracostal access of the left kidney. All cases of injury were identified after the procedure, with two stable patients' injuries identified on postoperative CT scan, and a third patient presenting with significant bleeding at removal of the nephrostomy tube. The spleen-preserving, conservative management strategy was successful, because no patients needed exploratory surgery.Splenic injury is a rare complication sustained most commonly during supracostal, upper-pole access to the left renal unit. When patients are hemodynamically stable, this complication can be conservatively managed, with prolonged nephrostomy drainage and observation in a monitored setting before and after nephrostomy tube removal.