Ten years after the first application, extracorporeal shock wave lithotripsy (ESWL) has gained world-wide acceptance as first choice therapy of urinary calculi. The introduction of different shock wave sources, shock wave coupling and imaging techniques have influenced treatment comfort, need of anesthesia, and costs of the device, but did not improve efficacy of treatment regarding complete disintegration of calculi without need for secondary treatments. Therefore the optimal device for lithotripsy providing high efficacy, no need for anesthesia, and inducing minimal tissue trauma has not been found yet. ESWL represents first choice therapy of ureteral stones without prior endoscopic manipulations. Under the conditions of fluoroscopic imaging and high shock wave energy stone-free rates up to 90% can be achieved. For the treatment of staghorn stones ESWL-monotherapy seems to be suitable for smaller calculi only, while larger stone burden classified by surface area calculation represents an indication for initial percutaneous approach. Although with both methods complete stone clearance cannot be achieved in more than 80% of cases, relief of symptoms and infection occurs more likely.