With miniaturization of instruments and refinement of surgical technique, the management of pediatric stone disease has undergone a dramatic evolution. While shock wave lithotripsy (SWL) is still commonly used to treat upper tract calculi, the use of ureteroscopy (URS) has dramatically increased and is now the procedure of choice for upper tract stone burdens less than 1.5cm at centers with significant experience. Percutaneous nephrolithotomy (PCNL) has replaced open surgical techniques for the treatment of large stone burdens greater than 2cm, with efficacy and complication rates similar to the adult population. Large institutional series demonstrate comparable stone-free and complication rates with SWL, URS, and PCNL, but concerns remain with these techniques regarding renal development and damage to the pediatric urinary tract. Randomized controlled trials comparing the efficacy of SWL and URS for upper tract stone burdens are needed to reach consensus regarding the most effective primary treatment modality in children.