Percutaneous nephrolithotomy (PCNL) has evolved many a fold and was originally described in supine position by Valdivia et al. In this position, the direction of the tract is posterior and thus preserves a low pressure in the renal pelvis, and thereby reduces the risk of fluid absorption and allows spontaneous clearance/washout of fragments by gravity-directed flow of fluid. Supine PCNL is feasible in most situations. It is an important tool for patients who have musculoskeletal abnormalities precluding prone positioning. It gives the surgeon a simultaneous opportunity to do flexible ureteroscopy. Mobility of the kidney may make the puncture difficult. Suctioning of the dust using the suction sheath in supine PCNL makes the procedure more effective.