Obtaining a precise percutaneous calyceal puncture gave way to the development of percutaneous nephrolithotomy, one of the first micro-invasive techniques described in urology. Both radiologist and urologist can perform puncture, sometimes in a collaborative effort. However, being followed by a true surgical procedure, it should be done in the O.R; perfect knowledge of the procedure is mandatory for every urologist. Standard guidance uses a fluoroscopic C-arm device, only able to guide the needle precisely towards the apex of the chosen calyx. Moving the C-arm with cephalad tilting will provide 3-D imaging. Ultrasound guidance is an alternative, but might be difficult with non dilated upper tract. CT guidance and retrograde puncture are rarely used. The access is to be adapted according to the patient (adult or child), type of stone (single or multiple access), or kidney position (eutopic or ectopic). Direct ad stable puncture entering the apex of the chosen calyx is a pre-requisite for easy and efficient subsequent nephrolithotomy.