Retrograde nephrostolithotomy in management of complex renal calculi. From October 1986 to July 1990 we evaluated 22 patients with complex renal calculi in 25 kidneys for initial therapy using retrograde percutaneous nephrostolithotomy. In 3 patients we could not attain renal access in a retrograde fashion. In the remaining patients residual fragments after percutaneous nephrostolithotomy were treated with a combination of extracorporeal shock wave lithotripsy (ESWL), chemolysis and retrieval of small calculi with a flexible nephroscope. Successful treatments were achieved in 6 of the 22 kidneys (27%) using percutaneous nephrostolithotomy alone and in 17 (77%) using all modalities. Retrograde and antegrade percutaneous nephrostolithotomy in conjunction with ESWL, chemolysis and flexible nephroscopy in the treatment of patients with complex calculi yield comparable success rates. However, retrograde percutaneous nephrostolithotomy can be performed without the aid of an interventional radiologist and it provides easy access to the nondilated collecting system. 