The introduction of shock-wave lithotripsy has radically changed the treatment strategy for the management of most renal calculi. However, many stones cannot be treated effectively with this form of lithotripsy, and are best managed with percutaneous procedures. Although shock-wave lithotripsy is the least invasive form of stone management, percutaneous nephrostolithotomy remains the treatment of choice for several forms of stone disease including: large stones, many cystine and struvite calculi, lower pole calyceal calculi, stones associated with anomalous renal anatomy, and stones in morbidly obese patients.