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OBJECTIVE To evaluate the effect of prepuncture on the double-tract percutaneous nephrolithotomy (PCNL) under ultrasound guidance for renal staghorn calculi. METHOD Double-tract or even multi-tract is necessary for the treatment of staghorn calculi. However, intraoperative injury, exudation, bleeding, and influence of original tract might lead to difficulty in second puncture, thus prolonging operating time, and even lead to puncture failure. We retrospectively reviewed the records of 178 patients with renal staghorn calculi who received double-tract PCNL in our department. Sixty-three patients received non-prepuncture double-tract PCNL (group A) and 115 patients underwent prepuncture double-tract PCNL (group B). In group A, the second tract was established after failing to further fragment by the first tract. In group B, based on the preoperative computed tomography, intravenous pyelography, and intraoperative ultrasound images, 2 optimal punctual positions were set. The first guidewire was manipulated in the pelvicalyceal system after successful puncture. However, we routinely performed the other puncture and a preplaced second wire was put into the collecting system as a potential second tract. RESULTS The mean operating time was longer in group A than that in group B (P = .033). There was no statistical difference between group A and group B in postoperative instant stone-free rate and final stone-free rate. In the non-prepuncture double-tract PCNL group, blood transfusion rate was 7.9% (5/63) and it was only 1.7% (2/115) in the prepuncture double-tract PCNL group (P = .042). CONCLUSION In the treatment of renal staghorn calculi, prepuncture double-tract PCNL can shorten operating time and reduce the occurrence of blood transfusion events. This new method might be worth generalizing.