Objective: To compare the efficacy, cost effect and safety of extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) for distal ureteric calculi by evaluating stone-free rates, retreatment rates, need for auxiliary procedures, associated complications and technical consideration with respect to patient satisfaction. Patient and method: 70 patients with single unilateral radiopaque distal ureteric stone ranges from 0.8 cm to 1.2 cm in diameter and ≥1.5 cm in length were enrolled in a prospective randomized trial. Patients were randomized to undergo URS (35) or ESWL (35). The electromagnetic Dornier lithotripter S was used for ESWL and a semi-rigid Olympus ureteroscope, 7° direction of view, angled ocular,8.6/9.8 Fr. x 43 cm, 6.4 Fr. channel was used for URS. Patient and stone characteristics, treatment parameters, clinical outcomes, and patient satisfaction were assessed for each group. Results: Patients in the ESWL group achieved a 77.1% overall stone-free rate (SFR) with a 74.3% retreatment rate and no auxiliary procedure was done. Complications occurred in 11.4% of patients treated with ESWL. Patients in the URS group achieved a 97.1% overall SFR with a retreatment rate of 8.6% and an auxiliary procedure rate of 100%. Complications occurred in 31.4% of patients treated with URS. Patient satisfaction was high for both groups, including 94.3% for URS and 77.1% for ESWL. ESWL were already at outpatient clinic so there were no admissions or hospital stay. While in URS group patients admitted with mean hospital stay 1.6±0.5 day. Conclusions: In the treatment of large distal ureteral calculi ≥ 1.5 cm, both URS and ESWL modalities are comparable but URS is recommended as a first option as it is more effective than ESWL regarding stone-free rate and it provides immediate stone clearance with lower retreatment rates and higher patient satisfaction.