ESWL has been used in clinical practice for more than 20 years. With the accumulation of clinical experience and the development of lithotripter technology, there are new changes in the understanding of indications, treatment principles and complications of ESWL. The third generation lithotripter has achieved multifunctionality and can be used for urological imaging diagnosis and adjuvant therapy in addition to ESWL. Currently, contraindications to ESWL treatment are pregnant women, uncorrectable bleeding disorders, obstruction in the urinary tract below the stone, severe obesity or skeletal deformities, high-risk patients such as heart failure, severe cardiac arrhythmias and active urological tuberculosis. The efficacy of ESWL is related to the size of the stone, but also to the location, chemical composition and anatomical abnormalities of the stone. (1) Size of the stone: the larger the stone, the greater the likelihood of needing retreatment. ESWL should be preferred for kidney stones less than 20 mm in diameter; stones larger than 20 mm in diameter and antler-shaped stones can be treated with percutaneous nephrolithotomy (PNL) or combined with ESWL . If ESWL is used alone, it is recommended to insert a double J tube before ESWL to prevent the formation of a “stone street” to block the ureter. (2) Location of stones: Pelvic stones are easily crushed, and stones in the middle and upper renal calyces are more effective than stones in the lower calyces. For those with an acute angle between the funnel of the lower calyx and the renal pelvis, a longer funnel length and a narrower funnel width, the removal of stones after ESWL is unfavorable. (3) Composition of stones: magnesium ammonium phosphate and calcium oxalate dihydrate stones are easy to crush, uric acid stones can be combined with lithotripsy for ESWL, and calcium oxalate monohydrate and cystine stones are more difficult to crush. (4) Anatomical abnormalities: malformations of the renal collecting system such as horseshoe kidney, ectopic kidney and transplanted kidney stones can affect the discharge of stone fragments and can be treated with adjunctive lithotripsy. (5) Number of ESWL treatments and treatment interval: The recommended number of ESWL treatments should not exceed 3 to 5 (depending on the lithotripter used), otherwise, percutaneous nephrolithotomy should be chosen. There is no definite standard for the interval of treatment, but most scholars, by studying the time of repair after kidney injury, believe that an interval of 10 to 14 days is appropriate. Most ureteral stones can be treated with in situ lithotripsy with satisfactory results and a low incidence of complications and side effects. Since ureteral stones are often relatively embedded in the ureteral lumen, there is a lack of a fluid environment around them that is conducive to stone crushing, which makes it more difficult to crush them compared with kidney stones of the same size. Therefore, ESWL treatment of ureteral stones usually requires a higher shock wave energy and a greater number of impacts. For complex stones (stones that are too large or very tightly packed), a combination of ESWL and other minimally invasive treatment modalities (such as ureteral stenting or ureteroscopic lithotripsy) is required. The efficacy of ESWL is related to the size of the stone, the degree of stone encapsulation by the tissue and the stone composition, and the re-treatment rate is higher for large and dense stones. ESWL is preferred for upper ureteral stones ≤1 cm in diameter, while ESWL, ureteroscopy (URS) and PNL can be used for stones >1 cm in diameter; ESWL and URS can be used for middle and lower ureteral stones. Most ureteral stones can be treated satisfactorily with in situ lithotripsy, while some ureteral stones require ureteral stent tubes to be placed through the stone or left underneath the stone. In situ lithotripsy can be helpful; it is also possible to push the ureteral stone retrograde into the renal pelvis before lithotripsy.