© 2013 Springer-Verlag London. All rights reserved. The prevalence of obesity has significantly increased over recent decades in the United States and other developed western countries. With the rates of obesity and rates of nephrolithiasis rising in parallel, there is a suggestion that the two processes share a common pathophysiology. Obesity presents numerous challenges to the clinician. bese stone formers have been shown to have high stone recurrence rates after treatment compared to nonobese patients with nephrolithiasis. Surgical management of nephrolithiasis in obese individuals may be more laborious, may require additional procedures to achieve similar results, and may pose a higher risk of procedural morbidity to the patient. Herein, we present clinical scenarios of how an obese patient can complicate PCNL and suggest various techniques to overcome these challenges.