Background: In order to reach the posterior upper-pole calyx of the kidney, which is the farthest back part of the kidney, a supracostal puncture is recommended for staghorn calculus management. Objective: To compare safety, operative time and efficacy of supracostal puncture versus subcostal puncture in percutaneous nephrolithotomy (PCNL). Patients and methods: Urology clinics at Zagazig University were the site for this prospective randomized comparison research. Fifty patients with an indication for percutaneous nephrolithotomy were enlisted and randomly assigned to one of two groups; in Group A, PCNL was performed through supracostal puncture. Patients in Group B had subcostal puncture for PCNL. Results: Hospital stay was 1.84±0.64 and 1.44±0.48 in supracostal and subcostal groups respectively without significant difference between groups. In supracostal puncture 36.0% had complication as (2 cases 8.0% had hydrothorax , 4 cases 16.0% parenchymal bleeding two of them need transfusion and 2 cases 8.0% had transient fever) and 1 case 4.0% had transient increase in serum creatinine regard subcostal puncture 28.0% had complication as (3 cases 12.0% had parenchymal bleeding just one of them needed transfusion) 3 cases 12.0% had transient fever) and 1 case 4.0% had transient increase in serum creatinine with no significant difference between groups. Supra group was 72 % stone free while subgroup was 64%. Conclusion: When treating staghorn renal calculi, the success rate was marginally higher in the supracostal puncture group compared to the subcostal puncture group with nearly similar complication rates in both groups.