Objective The goal of this study was to compare the effectiveness and complications of ureteroscopic pneumatic lithotripsy (URS) and extracorporeal shock wave lithotripsy (SWL) in the management of patients with proximal ureteral stones. Methods In this trial, 150 patients presenting with proximal ureteral stones at the Department of Urology of Nishter Hospital Multan from November 2018 to November 2019 were allocated 1:1 to undergo URS or SWL. The presence of stone fragments <4 mm on follow-up was regarded as being stone free. The study outcomes included stone-free rates after first, second, and third treatment sessions and stone retropulsion into the kidneys. Results A total of 75 patients each underwent URS and SWL. The mean procedure times for SWL and URS were 61.61± 3.21 and 85.01±6.75 minutes, respectively (P=0.000), and the mean numbers of procedures were 1.51±0.49 and 1.01±0.42, respectively (P=0.000). Stone-free rates after the first, second, and third sessions of SWL were 64%, 77.3%, and 94.7%, respectively, whereas stone-free rates after the first, second, and third sessions of URS were 86.7%, 92%, and 100%, respectively. Rates of stone retropulsion into the kidneys in the SWL and URS groups were 0% and 6.7%, respectively (P=0.000). Conclusion Compared with SWL, URS had significantly higher stone-free rates in patients with proximal ureteral stones. Treatment costs and hospital stay were lower in the SWL group, whereas complication rates were comparable.