A series of 53 percutaneous nephrostomies and a literature review of 516 such procedures are presented. The selection of patients with supravesical urinary obstruction, urinary fistulas, and renal calculi is discussed, and the concept is advanced that percutaneous nephrostomy is more than a temporizing preoperative procedure. The available techniques are compared; modified instrumentation for balloon catheter insertion, a combination of fluoroscopic with real-time ultrasound guidance, and some additional principles of subsequent management are introduced. Successful results can be expected in over 90% of percutaneous nephrostomies, with major complications limited to 4% and minor complications to 15%. The limitations of percutaneous nephrostomy and the role of surgical nephrostomy are discussed.