To review the history of percutaneous nephrolithotomy (PCNL) in children, describe technical considerations, including advancements in equipment, and discuss future directions.A comprehensive literature review was performed using MEDLINE/PubMed to evaluate the use of PCNL in the pediatric population, including historical background, indications, operative techniques, and outcomes.PCNL was first applied to the pediatric population in the 1980s using adult-size instruments. Although there is still concern for potential renal damage in relatively small kidneys, initial investigations have demonstrated its safety and efficacy in children. Operative techniques are similar to those used in adult patients, but considerations specific to pediatric populations must be addressed. Modifications in technique including "mini-perc" access have reduced postoperative morbidity without an appreciable difference in outcomes. Technologic improvements, including miniaturization of endoscopes and advances in energy sources for stone fragmentation, have facilitated stone-free rates comparable to those of adult populations with PCNL monotherapy and sandwich shockwave lithotripsy therapy with minimal postoperative morbidity.Technologic advancements and refinements in technique have facilitated the successful application of PCNL in the pediatric population. As a result, PCNL has now replaced open surgery as the treatment of choice for large stone burdens in children of all ages.